A STUDY OF PSYCHOLOGICAL ASSESSMENT AND TREATMENT...

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A STUDY OF PSYCHOLOGICAL ASSESSMENT AND

TREATMENT OF ADOLESCENT OBESITY

CHAPTER-1

INTRODUCTION

Although the problem of obesity has been with us for centuries, the early 21st century has seen the development of a global epidemic of obesity in many countries (W.H.O 2003; cited in Baur, 2003). It appears to be one of the today's most common health problems (Stein, 1987) Its significance requires constant emphasis because it is associated with increased mortality, predisposes to the development of many physical diseases (like Type2 diabetes, hypertension, arterial changes, liver problem), behavioural disorders and diminishes the effectiveness and happiness of those affected by it (Ebbeling, Pawlak and Ludwig, 2002). Obesity and overweight are serious health problems. Strictly speaking,

obesity connotes an excessive fat accumulation in adipose tissue whereas

overweight indicates an excessive body weight in relation to height. However, these

terms are often employed synonymously. It is now estimated that over 100 million

people worldwide are obese and 58 million of these are in developing countries

(Shetty, 2003) .The prevalence of obesity and overweight is escalating rapidly

worldwide. Some scientists (Hill & Peter, 1998; Popkin and Doak, 1998) concluded

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that obesity has already reached epidemic proportions in developed countries and

their observations are that the developing world might fall into its grip very soon.

Industrialized and developed countries are showing a rise in overweight persons

among their populations along with changing economic conditions. Indeed, obesity

is now so common that it is replacing the mere traditional public health concerns,

such as under nutrition and infectious diseases, as one of the most significant

contributors of ill-health. Furthermore, increasing prevalence of obesity in a

population and particularly among girls is an early indicator of emerging health

burden due to non-communicable chronic diseases like cardiovascular diseases,

hypertension, diabetes, respiratory problems, sleep apneas and orthopedics

complications.

Obesity in childhood and adolescence is also very common. The majority of European

countries have prevalence rates of overweight and obesity higher than 10 percent for 10 years

old boys and girls. Of even greater concern is that several countries have rates above 30

percent as in Greece, Italy or Malta (Livingstone, 2000). The prevalence of obesity has

increased dramatically over the past three decades. This increase has been noted in both adults

and children. However, the increase in children and adolescents is a major concern among

healthcare professionals and policy makers because obese children and adolescents have an

increased risk for becoming obese adults. Currently, in America approximately 15.3 percent of

children (ages 6-11) and 15.5 percent of adolescents (ages 12-19) are obese. About 19-23

percent Australian children and adolescent were overweight or obese (Magarey, Daniels, and

Boulton, 2001). A prevalence of obesity was reported to 22 percent in the age groups of

11-21 years in Saudi Arabia (Al-Subaie, 2001) .The most alarming increase in obesity has

been observed in Great Britain where nearly two-thirds of adult men and over half of adult

women are overweight or obese (Ruston, Hoare, Henderson, and Gregory, 2004).

Globalization, economic development, and other factors such as commercialization of agriculture and urbanization have led to changing patterns of living, which can be viewed as part of the nutrition transition. Nutrition transition is generally defined as the


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shift away from diets high in fiber and complex carbohydrates toward more energy-dense diets that are high in sugars, refined foods, and saturated animal fats, coupled with increasingly sedentary lifestyles. These dietary and lifestyle shifts have been attributed to change such as the low cast of highly refined oils and carbohydrates, the move toward motorized transportation, the increase in sedentary occupations as well as ownership of television.

Overweight and obesity and their health consequences have been

recognized as major public health problems worldwide. A significant increasing

trend in the prevalence of overweight and obesity among children and

adolescents has been documented over the last few decades in developed and

in developing countries (Chinn & Rona, 2001). The most significant long-term

consequences of childhood and adolescent overweight and obesity are their

persistence into adulthood with all of the attendant health risks (Must & Strauss,

1999; Power, Lake, and Cole, 1997), such as dyslipidemia, hyperinsulinemia,

type 2 diabetes, hypertension, cardiovascular diseases, arthritis, and

behavioral problems.

Obesity in children and adolescents is gradually becoming a major public

health problem in many developing countries, including India (Popkin and Doak,

1998). In Indian mythology, overweight was seen as a sign of inner contentment,

with some statues and other representations of several of the gods often showing

signs of central obesity. Obesity is increasing in India also. In a study, Asthana

(1993) reported 30 percent obesity in adult women. As with many other countries in

the world, the cause of much of the increasing level of obesity has been the rapid

nutritional and lifestyle changes, particularly prevalent in urban areas.The prevalence

is higher in urban than in rural areas (Kaur, Kapil, and Singh, 2005). The results of

studies among adolescents from parts of Punjab, Maharashtra, Delhi, and South India

revealed that the prevalence of overweight and obesity was high (11% to 29% )

(Kaur, Kapil, and Singh, 2005). In Ludhiana, Punjab, urban children in the age group

of 11 to 17 years of age were more overweight (11.6% ) than their rural

counterparts (4.7% ) (Kaur, Kapil, and Singh, 2005). Prevalence of obesity in


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affluent adolescents in Ludhiana was 3.4 percent and overweight was 12.7 percent. A

significantly greater number of boys (15%) were overweight as compared to girls

(10%) (Aggarwal, Bhatia, and Sobit, 2008). Prevalence of obesity in affluent school

children in Delhi was reported to be 7.4 percent (Kapil, Singh, Pathak, Diwedi, and

Bhasin, 2002), whereas Khadikar and Khadikar (2004) reported a prevalence of

obesity to be 5.7 percent and overweight 19.9 percent among affluent school boys

in Pune. In another study coducted in Pune, Maharashtra, it was found that among

1228 boys in the age group of 10 to 15 years 20% were overweight, whereas 5.7%

were obese (Kaur, Kapil, and Singh, 2005). A study carried out in Ludhiana, Punjab,

on school children in the age group of 9 to 15 years revealed that the overall

prevalences of overweight and obesity were 11% and 14% respectively (Kaur,

Kapil, and Singh, 2005). Another study carried out in Delhi, among 5000 private

school children in the age group of 4 to 18 years in 2002 by the Nutrition

Foundation of India revealed that the prevalence of overweight was 29% (Kaur,

Kapil, and Singh, 2005). A similar study conducted in Chennai, in South India,

showed that the prevalence of overweight was 17% and of obesity was 3% (Kaur,

Kapil, and Singh, 2005).

DEFINITION OF OBESITY The term obesity has been defined differently by different researchers. They have given various meanings of this term. Albrink and Meig (1965) stated that "obesity is that state in which the accumulation of reserve fat becomes so extreme that the functions of the organism are interfered with". Berry (1968) defined the term obesity as excess of fat in body often causing its bulkiness. Stuart and Davis (1972) stated obesity as excessive proportion of body fat in the total body mass. Craddock (1973) referred that obesity is a condition caused by an excessive storage of body fat. U.S Department of Health Education (1997) defined "obesity as bodily condition marked by excessive generalized deposition and storage of fat" Obesity is defined as an excessive accumulation of body fat. Obesity is

present when total body weight is more than 25 percent fat in boys and more than 32

percent fat in girls (Lohman, 1987). According to the Centers for Disease Control,


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obesity is defined as "the condition of an excessively high amount of body fat or

adipose tissue in relation to lean body mass." A more commonly-known definition

of obesity is that of an individual's weight being 30% or more above what is

considered normal as defined by a standardly-accepted height/weight chart (e.g. The

National Center for Health Statistics or Metropolitan Life Insurance Company).

Overweight and obesity are also commonly determined by calculating an individual's

body mass index. Obesity is an excess proportion of total body fat. A person is

considered obese when his or her weight is 20% or more above normal weight. The

most common measure of obesity is the boddy mass index or BMI. A person is

considered overweight if his or her BMI is between 25 and 29.9; a person is

considered obese if his or her BMI is equal or more than 30.

"Morbid obesity" means that a person is either 50%-100%

over normal weight, more than 100 pounds over normal weight, has a BMI of 35 or

higher, or is sufficiently overweight to severely interfere with health or normal

function. Obesity becomes "morbid" when it reaches the point of significantly

increasing the risk of one or more obesity-related health conditions or serious

diseases (also known as co-morbidities) that result either in significant physical

disability or even death. According to the National Institutes of Health Consensus

Report, morbid obesity is a serious disease and must be treated as such. It is a

chronic disease, meaning that its symptoms build slowly over an extended period of

time.

A thin line exists between overweight and obesity. Overweight is defined as a body mass index (BMI) of 25 to 29.9 kg/m 2 and obesity as a BMI of = 30 kg/m 2. However, overweight and obesity are not mutually exclusive, since obese persons are also overweight

Obesity results in an increase in the size of the adipose tissue. The

adipocytes are a group of special cells that contain fat. These fat cells are

developed at certain points of human growth. During infancy, adolescence and

pregnancy the body's potential for fat cell development is mobilized and


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adipose tissue is made at a faster rate than at any other times during life. The

growth depends upon nutritional and environmental factor (Haskew and

Adams, 1984). The adipose tissues are sensitive to nutritional changes and

need to be balanced since they are used as storage bins for fat. In studies

done on these cells, it appears that larger cells constitute obesity. It also seems

that adipocytes from a fat person do not release fat as easily as adipocytes

from a thin person. Scientists have found that the development of too many fat

cells during childhood may signal the beginning of a lifelong weight problem

and that fat cells, once acquired last forever (Lansky, 1990). The size of these

cells can be reduced by limiting calories but it is almost impossible to reduce

the number of cells. Therefore these cells cannot withstand a large “energy in”

and a small “energy out.” When this occurs, we see a rapid weight gain.

Body structure also needs to be considered when discussing obesity. The three types of body structures in humans are endomorphy, ectomorphy and mesomorphy. Endomorphy describes an individual having a large body with short arms and legs and having a tendency to be soft and round with substantial fat deposits; ectomorphy indicates a small body with long arms and legs and having a tendency to be thin and bony; mesomorphy refers to an individual that is aesthetically proportioned and having a tendency to be heavily muscled. Obesity definitions vary with body structure and gender, since women generally need more body fat than men. There is an implication that there is some relationship between body frame and the likelihood of having excess adipose tissue. Ectomorphs are said never to become fat and mesomorphs do not show fluctuation of food intake with changes in physical activity (Mayer, 1968). Therefore, it may be true that a link between body type and energy consumption does exist.

Causes of obesity

As with adult onset obesity, childhood and adolescent obesity has multiple causes centering on an imbalance between energy intake (Calories obtained from food) and energy expenditure (Calories expanded in the basal metabolic rate and physical activity). Adolescent obesity most likely results from an interaction of biological, environmental, familial, social, nutritional, and


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psychological factors.

Biological Factors: There are complex regulatory pathways in the human body that influence body weight. Certain hormones produced in the body can signal the brain to affect our appetite and energy expenditure. During conception, a fetus receives many pairs of genes; one half of each pair derived from the mother and one half from the father. Research shows that several genes have been associated with obesity and that some genes do play an important role in body size and body weight. In studies completed in the early 1900's, physicians noted that obese patients had at least one obese parent, if not two. A child with two obese parents has a 70-80 % chance of becoming obese and a child with one obese parent has a 40-50 % chance (Lansky, 1990). There is much controversy surrounding the “Nature versus Nurture” aspects of obesity. Genetics does influence obesity; however environment is also considered a major contributing factor. It seems likely that there is a complex interaction between genetics and environment rather than one or the other being the sole determinant. Heredity, including a number inherited genetic disorders (such as Prader-Willi syndrome and Bardet-Biedl syndrome), and gene mutations may contribute to rising incidents of obese individuals. However, the genetic underpinnings of human behaviour is often a contentious issue , with some arguing that human choice determines the range of behaviours that are increasingly being linked to genes, such as alcoholism and addictions; overweight and obesity; and such things as impulsivity, angry outbursts, anxiety, depression, and personality traits such as optimism and pessimism. It has been argued that even reporting genetic research is irresponsible because it might cause an excuse for obesity or addictive behaviour, rather than adopting healthier behaviours and lifestyles.

Obesity (and thinness) tends to run in families. In a study of adults who were

adopted as children, researchers found that participating adult weights were closer

to their biological parents' weights than their adoptive parents. The environment

provided by the adoptive family apparently had less influence on the development of

obesity than the person's genetic makeup. In fact, if your biological mother is heavy


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as an adult, there is approximately a 75% chance that you will be heavy. If your

biological mother is thin, there is also a 75% chance that you will be thin (Bray and

Ryan, 1999). Nevertheless, people who feel that their genes have doomed them to a

lifetime of obesity should take heart. Many people genetically predisposed to

obesity do not become obese or are able to lose weight and keep it off.

One misconception about genes and obesity is that there is an "obesity gene", or one gene that causes obesity. In fact , there are many genes that have been implicated in obesity, and these genes include those that play a role in how insulin is regulated; those that determine how various hormones are secreted and used; those that regulate how and where fat is stored; and those that govern how or whether fullness or satiation is felt or experienced. These and other genes play an important roles in eating behaviours, energy use and metabolism, and in the experience of hunger and the desire for food. When a number of genes contribute to a particular behaviour or condition, this is known as having a polygenetic cause. According to some, having a polygenetic cause, as opposed to having a single genetic mutation or difference causing a disease or medical condition means that the genetic factors are less meaningful or even insignificant. Some view these genetic factors as merely having some influence over, rather than a causative relationship with, obesity. Another view is that because environmental, social, and psychological factors also have roles in determining various aspects of food intake and energy expenditure, biology and genetics appear to set the parameters within which these behaviours and conditions occur.

Environmental factors:

Although genes are important factors in many cases of obesity, a person's environment also plays a significant role. Environmental factors include lifestyle behaviors such as what a person eats and how active he or she is. For example, during the times of food shortages there will be a great less obesity than during the times when food is available and abundant, demonstrating the environmental, behavioural, and societal factors that also govern food intake. However, during times of food availability and abundance, there are individual differences in feelings of hunger and satiation, in the ability to metabolize food and expend energy, and in the way nutrients are used and stored. As a result, not every individual will gain weight during a time of great food availability and abundance, but


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some will. Living continuously in times of food abundance, especially the abundance of processed, sugary, fatty, and salty foods has been called living in a "toxic environment", one that sets the stage for unhealthy food behaviour and weight gain to occur. Although not everyone in a toxic environment will become obese, those who are predisposed to do so, due to presence of genetic variations and differences, will most likely put on excess weight and have great difficulty taking it off (Stein, 2008).

Additionally, it has been shown that human body is built to respond the

changed according to environmental conditions and demands. During times of food

shortage, human metabolism slows down, so as not to use up the energy it has taken

in too quickly. Historically this has been played out during times of food shortages,

seasonal changes in food availability, and during the time of extreme environmental

condition such as famine. The ability for metabolism to slow down during these

times would have provided an evolutionary advantage, enabling individuals with this

ability to use much more slowly that which was in limited supply. Humans have been

shown to react the same way to self-imposed food restriction, such as

weight-reducing diets, and instead of losing weight due to limited food intake, the

body adjusts to these limitations by slowing down metabolism and the need for

food. As a result the dieter, overtime, needs less and less food as the body adjusts to

reduced amounts and availability of food supplies.

Along most city streets it is hard to miss the fast-food restaurants on every block; McDonalds, Burger King, Wendy's and Roy Rogers, just to name a few. What do these places offer? For most it's a quick, calorie laden meal often containing enough fat to fulfill an entire day's allotment. Adolescents are particularly vulnerable to these places and for the inner city child this is often their “special” dinner out. Just as fast-food restaurants attract the adolescent population, so does the constant bombardment of advertisements. The sole purpose of advertising is to entice and persuade individuals to buy products. Advertisements for candy, gum, soda, snacks and fast foods target the youth market and can influence food beliefs and eating patterns. Commercials tend to encourage snacking between meals.

The abundance of fast-food restaurants may provide a source of convenient


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and a relatively cheap, tasty food, these establishments typically do not offer nutritious foods such as fruit and vegetables. Instead a typical fast-food meal is very calorie dense. Individuals who eat at fast -food restaurants tend to consume more fats, sugars, and carbohydrates and fewer fruits and non-starchy vegetables than individuals who do not eat fast food. The United States Department of Agriculture's food intake surveys indicate that between 1977 and 1996, daily caloric intake from food eaten outside of the home increased from 18 to 32 percent, with a 40-percent increase between 1987 and 2000 in the proportion of the population that reported eating there or more commercially prepared meals per week. Food-away-from-home expenditures have increased to account for about half of total food expenditures, and fast-food restaurants account for nearly 40 percent of the away-from-home market. The rising consumption of restaurant fare has coincided with an increased prevalence of obesity, and several studies have reported a positive association between the frequency of eating at fast-food restaurants and body weight. In addition, a higher per capita number of restaurants have been positively associated with a higher body mass index (BMI). People, particularly children and adolescents are exposed to large amount of advertising in a variety of avenues. For instance, it is estimated that children are exposed to tens of thousands of television advertisements each year. Among these advertisements, foods are most frequent products being promoted. However the food industry has been reallocating marketing rupees toward other venues, such as the school setting and the internet. The pervasive nature of food marketing, as well as the increasingly sophisticated methods used to advertise to children, might be related to dietary preferences. Researchers have proved that exposure to advertisements greatly affects children's attitudes toward, and interest in, particular foods. Concern has developed over food marketing to children because many studies have linked food marketing to food choices of children. The majority of studies conducted on the effects of advertising to children have shown that children choose advertised products significantly more than do children who were not exposed to advertising. Also, advertising increases children's attempt's to influence purchasing decisions of their parents, a concept referred to as "pester power". Further, the majority of foods and beverages advertised to children are high in sugar and fat, and low in nutrients. For example, the Institute of Medicine has concluded that the majority of television advertisements for food and beverage products for children are energy dense but not nutrient dense. The Institute of Medicine also has concluded that advertising, at least on television, can influence children and youths


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such that they both prefer these types of food products and request them for more.

Parental and Home Environment: A number of factors related to home and parental environment may have an effect on children's eating habits and consequent weight status. Home and parental environment have also received much attention by researchers investigating factors related to development of obesity, because it is in the home that most early experiences with food and early experiences occur. Some demographic variables of home have been found to relate to children's eating, level of physical activity, and weight status. While evidence on the socioeconomic status is mixed, many studies suggest an association between low income and increased rates of obesity (Benton, 2004). This may be due to the fact that in lower households, higher weights in early childhood may be considered as a mark of good health, foods such as fruits and vegetables may be less available, and the environment may be less stimulating and conducive to physical activity. Parental education may also play a role. Also related to childhood obesity is a single-parent home environment. Children from single-parent homes tend to eat fewer meals but more snacks (Golan and Crow, 2004). This erratic eating schedule may be result from single parent's need to work long hours as the sole household provider and may be responsible for increased obesity risk. Children and adolescents who eat more meals with the family at home tend to have healthier eating habits. However in recent years, eating has been taking place outside of the home environment more frequently, and children and adolescents have been making more decisions regarding family food selection and meal preparation. Meals eaten outside of the home, such as in the fast-food venues or restaurants, tend to be higher in fat and energy content (Hayons, 2008). Additionally, when adolescents are responsible for their own food decisions, they are more likely to engage in erratic eating patterns and to eat more junk foods. Family meals provide a protective environment against such factors.

Another variable related to home environment that has been found tolerate to obesity is the availability and utilization of technology that promoted sedentary behaviour (e.g., television, video games, etc.). In particular television viewing has been linked with the development of obesity. Parents' attitudes and behaviours toward eating and physical activity can also have a significant effect on those of


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their children. Parents' energy, fat, fruit and vegetable, snack and soft drink intake and level of physical activity have been consistently positively associated with that of their children. Parental disordered eating behaviours, such as food restriction and disinhibition while eating, are often mirrored in their children's eating habits. The research demonstrates that parents modeling of eating and exercise behaviours impacts children's habits (Benton, 2004). For instance, children are more likely to sample a novel food if they see their mother consume this object. They are more likely to accept a food if they are offered the food by their mother. Additionally, parental involvement in physical activity often predicts the child's engagement in such activities.

Much evidence suggests that parental approaches to feeding their children can have a direct or indirect effect on a child's eating and weight. The parent feeding variable most consistently related to childhood overweight is that of dietary restriction. In other words, parents who restrict their child's access to foods or otherwise impose strict limits on their child's eating may be inadvertently encouraging habits that lead to increased risk of obesity (Golan & Crow, 2004). There are a number of explanations for this connection. Studies have demonstrated that restricting a child's access to a palatable food can increase the desirability of and preference for that food. Children will therefore consume more of the food when restrictions are removed. Additionally, by placing a high level of restriction around feeding, parents may be encouraging children to pay more attention to external cues, rather than their internal sense hunger and satiety. The effect of parental restrictive feeding practices may be most profound in samples of children who are already overweight. Parents are more likely to place restrictions on their child's eating if the child is overweight. However, this practice may be especially detrimental. Studies have shown that overweight girls, whose mothers place restrictions on their eating, eat more in the absence of hunger than leaner counterparts, whose mothers place restriction on their eating, as well as peers whose mothers do not place restrictions on eating (whether overweight or lean) (Neumark-Szainer, 2005).

The relationship between general parenting style and variables relating to child's eating, physical activity, and weight has received less attention. However there is suggestion that a parenting style characterized by support, communication, and responsiveness coupled with clear limit setting may lead to healthier eating and


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increased physical activity in children. Additionally, extreme disorganization, neglect, and abuse in some cases have been linked with the development of severe obesity and eating disorders (Hayons, 2008).

Parent's attitudes toward their child's weight may also have an impact on the

child's eating behaviours and weight. Children who receive negative comments

regarding their weight at home or who perceive their weight as being very important

to their parents tend to engage more in dieting and unhealthy weight control

behaviours. These behaviours, in turn, increase the child's risk for development of

obesity and eating disorders. Additionally, overweight children report benefiting

from parental support, rather than dieting advice. Researchers suggest that parents

focus more on encouraging healthy eating in children, rather than promoting a

particular body weight or shape (Ritchie, 2005).

Familial factors:

The risk of becoming obese is greatest among children and adolescent who have obese parents (Dietz, 1983).This may be due to powerful genetic factors or to parental modeling of both eating and exercise behaviours, indirectly affecting child's energy balance. The study shows that social networks influence weight and obesity. The study found that people were more likely to be overweight if their social groups were (Dietz, 1983).

Results of researches have pointed out that obesity can be "socially

contagious", meaning that people tend to eat as their friends and family do. When

friends and family become obese, their companions tend to follow suit. Researchers

found that a person had an increased chance of becoming obese if their social

network was obese. The risk increased 57% if a friend was obese, 40% if a sibling

was obese and 37% if a spouse was obese. (Christakis and Fowler, 2004).Not only

do friends influence each other to become obese; having more that one obese friend

increases the risk even more.

Obesity data was gathered over a period of 32 years on over 12,000 people who participated in the Framingham Heart Study (2001). The participants were


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weighed every few years, at their checkups. At their checkups, the participants named friends and family that the Framingham Heart Study could contact. Researchers computerized the contact information and mapped the social network of each participant. Researcher than traced trends of obesity through clusters of social networks of the participants .According to the findings of the study, family and friends influenced the participant's chances of obesity. Immediate neighbors did not affect obesity rates, suggesting that findings were not related to social class.

Several other factors like gender, natural weight gain, and the tendency of people to associate with similar people have also been studied as the obesity has become a growing health problem. The prevalence of obesity has increased over recent years from 23% to 31%. While the study did not offer conclusions as the reason for the social phenomena of social networks influence on weigh gain, there are some possible explanations. Possible explanations include inactivity in social networks, food consumption in a group, influence on eating habits, adoption of similar exercise patterns, adoption of lifestyle behaviors such as smoking and tolerance for obesity

The data did not show how obesity spreads through social networks, but social norms do appear to play a role. The influence appears to be stronger among same sex pairs, meaning that same sex friends were more likely to influence each other than spouses. While friends appeared to influence each other to obesity, the opposite was also true. Researchers found that when a friend loses weight that their social network may follow suit. People can use this information to be successful in their efforts to reach normal weight. Friends, siblings and spouses who agree to convert to healthy lifestyle habits and weight loss diets increase the chance of weight loss success for all concerned. Forming bonds with people who of normal weight may help an obese person get a different perspective on weight loss and encourage them to success. A gym or health club with normal sized people may provide the healthy motivation a person needs to reach normal weight.

Social Factors:

Cultural influence and socio-economic pattern have a strong influence on the prevalence of obesity. The first evidence of the influence of social factors came from the Midtown Manhattan Study (Moore, Stunkard, and Srole, 1962). Subjects consisted of 1660 adults, between age of 20 and 59, who were selected by stratified random sampling. There was a marked inverse relationship


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between the prevalence of obesity and socio-economic status. The prevalence of obesity among women of lower socio-economic status was 30 percent, falling to 16 percent among those of middle status and to only 5 percent in the upper status group.

There is a higher prevalence of obesity in lower socio-economic groups than in upper income group. Among the highest income group (i.e. most educated and affluent) only 4percent were overweight, as compared to 36 percent in lower socio-economic group (Goldblatt, Moore, and Stunkard, 1965).

The Ten State Nutrition Survey (1972) showed that there was significantly more obese in the lower socio-economic groups, as assessed by skinfold thickness. Ethnic differences were also present. Black males were consistently less obese than white males. Black women, on the other hand, showed a consistently higher prevalence of obesity at all ages than white women.

These variations in the prevalence of obesity between different social classes and races are more likely to reflect general social pressures than individual metabolic disorders or psychological disturbances. The explanation of these findings incorporates the notion that while we all tend to put on weight as we grow older; more people in the upper social classes care enough about such weight gain to do something about it. In other words, it is not the tendency to become fat, but the concern is being overweight, which distinguishes women of the upper socio-economic classes from their less disadvantaged contemporaries. There is some evidence to support this view; Mckenzie (1967) showed that at a given time twice as many English women in the upper social classes (22%) were actively dieting to lose weight, as compared to lower social classes (11%) women practicing dieting.

In a study, Musaiger and Ansari (1992) used a sample of 420 women who had attended a physical fitness programme to study the association between obesity and social factors. Subjects were grouped in to obese and non-obese. Age, education, employment, marital status, family size, and practicing exercises before joining the fitness programme had a significant association with obesity while ownership of cars, availability of housemates, and family history of obesity had no significant relationship.

Obesity carries a social stigma (Allon, 1976; Cohman, 1968). This was most clearly shown by studies with children and adolescents who were asked to


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express a preference for various forms of disability, including obesity (Goodman, Richardson, Dornbusch, and Hastorf, 1963). In all classes, the obese child was liked least. The study of Richardson (1961) left little doubt about the social stigma attached to an obese child. The potential disadvantages of obesity have been emphasized in studies on social mobility and dating behaviour. Elder (1969) indicated that physical appearance was the most important factor for women in attracting upwardly mobile men for marriage. Because of the attitudes about physical attractiveness and the relatively unattractive view of obesity by many children and adults, it is easy to understand the relative social positions and feelings of many obese individuals. This has been emphasized by Monello and Mayer (1963) in a study on the attitudes of obese adolescent girls. They observed that these individuals showed excessive concern with one's status, acceptance of dominant values in the culture and passivity. They noted that all of these reactions or characteristics of obese adolescent girls made them to behave in isolation as a minority group, in response towards the dominant culture of non-obese. The social stigma of obesity affects the life of nearly every overweight person. Obese persons suffer not only from the social and sometimes physical disability of being overweight, but they are blamed for their condition. Unlike persons with other physical disabilities, overweight persons are given labels such as self indulgent, gluttonous, lazy etc. The overweight person internalizes at an early age society dim view and then embarks on a career of unsuccessful diet.

Nutritional factors:

Manipulation of diet can produce obesity in two ways: by changing the frequency of eating or by changing the composition of diet.

Frequency of Eating: The frequency of food composition plays an important role in the genesis of obesity. It is known that taking one meal per day as opposed to two or three has metabolic consequences independent of calorie intake. Epidemiological studies have shown a clear negative correlation between number of meals and obesity, the fewer the meals, the greater the tendency towards obesity (Fabray, Hejda, Cerney, Osanoova, and Peacher, 1966). The frequency of eating also changes the metabolism of glucose and the concentration of cholesterol. Cohn (1964) found that when normal volunteers ate several small meals a day, they had lower concentrations of cholesterol than when the same total intake was eaten in a few large meals. This reduction of cholesterol with frequent ingestion of small meals has been confirmed in several other studies (Jagannathan, Conell, and


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Boverige, 1964; Irwin and Freeley, 1976). Glucose tolerance curves also improved when eating three or four meals as compared with one or two large meals (Fabray et al. 1964). In brief it can be said that frequency of eating is inversely related with obesity.

Composition of Diet: The calorie intake of lean subjects was the same as those of overweight subjects for all ages and both sexes (Nutrition Canadian Survey, 1973). Thomson, Billeweiz and Passmore (1961) also reported that calorie intake does not rise with body weight.

Obesity can occur only as a result of energy intake in excess of energy expenditure. If an individual ingests and stores 100 kcal more than is required/ day, then 36500 Kcal will accumulate during the course of one year and this will result in a weight gain of 46 Kg in one year. There are many factors which influence food intake and energy output viz. age, somatic and emotional profiles, socio-economic and genetic factors.

Overeating, if understood in terms of eating more than average, is not typical of obese subjects. "Overweight" only in a relative sense, is that their energy expenditure is less than the energy intake. Since the physiological evidence at rest and during exercise is in contrastable, it follows that obesity is generally associated with diminished physical activity. Johnson, Burke, and Mayer (1956) indicated that obese subjects as a rule does not eat more than non-obese subjects, and many indeed less.

The work of Schachter (1968) has demonstrated that the factors that govern an individual's eating behaviour era related to his weight i.e. weight controlling for the person. The study showed that: (1) the more an individual weight the less responsive he is to internal physiological cues indicative of nutritional state, (2) the more an individual weights, the more responsive he is to external cues or environment related cues. Thus overweight individuals responded to external rather than to internal cues.

The higher intake of energy by the overweight and obese subjects could be one of the factors contributing to their energy intake been lower their RDA, the possibility of some other causative factors also exist.

In another study Shah and Robert (1991) examined the studies that investigated food intake, physical activity, basal metabolic rate and thermogenesis


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etiology. Energy intake appears to be only weakly related to obesity, but diet contribution especially dietary fat may make significant contribution to body weight. Physical activity, which accounts for about 15 to 20 percent of the total energy expenditure in a sedentary person, may be a function of obesity with lower levels of activity with severely obese.

Psychological Factors:

Two types of obesity have been identified: reactive obesity and developmental. The reactive obesity results from ingestion of excess of food as an emotional reaction to situations in the environment. The developmental obesity begins in infancy and caused by a fundamental feeling of rejection by mothers towards her child. The following general psych dynamic causes have been considered to be responsible for overweight and obesity.

A lack of coping skills: This means that there is an inability to manage life

in a practical way. Often there is an inability or lack of skill to deal with an emotion,

to process it, to work with it and to cope with it. Individuals with eating disorders

only know how to deal with their problems through food and exercise. Most of us

lack coping skills for at least some areas in our lives. Some people may stick at a

very primitive way of dealing with the world. They may be called as orally fixated

(Freud's theory). That is, they are stuck at an oral point of coping with the world.

This means that everything in terms of how they cope with the world is done around

the mouth. Besides eating, other oral fixations include smoking and drinking. The

other important concept that goes with this phase is "instant gratification". This is

the sense of time urgency of wanting everything now! There is an inability to wait.

They fail to recognize and respond adequately before it is too late because they do

not have the appropriate skills. For example, in a stressful situation, the obese

person reaches for and eats the doughnut before he/ she even thinks about any other

options. This brings to the next point. They cannot stop and think because the

appropriate skill is often inhibited by fear, anxiety or deeper issues. Any emotion

can prevent an individual from actually using a practical skill to deal with the

situation. Emotions are trigger factors which can either get in the way or they can

signal that an action is required. It can be explained in the inverted U hypothesis.


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Up to point X they have a positive experience and they are able to take action. Thereafter there is a decrease in their ability to take action. For example, if a student is studying for an exam, enough anxiety will motivate him/her to study but too much anxiety will prevent this. Any stress, emotion, experience, etc, can be a beneficial experience. However, too much of anything can overload the ability to cope. People stuck in the oral phase have a very low tolerance level which they deal with through instant gratification. Compare to the curve above, theirs would look like this. (Note the smaller curve indicating the lower tolerance level).

They lack confidence but this is often body specific: These individuals can be quite high functioning in other areas of their lives but they are not confident about their bodies. They feel particularly threatened in situations which require that they look physically good e.g. going out to a function.

There is a poor body image and the body image itself is often distorted. A distorted body image is a very specific phenomenon. It means that he/she looks in the mirror and when he/she weighs 45kgs he/she believes that he/she weighs 65kgs. It is a distortion, not a slight maladjustment. When these individuals look in the mirror they do not see the reality. The fat person seldom realizes how big s/he is; while the anorexic always thinks he/she is overweight.

There is an obsession with weight/food and the approach to this is often extreme or all-or-nothing. They constantly think about food. Being obsessive as well as being all-or-nothing are both defense mechanisms. All-or-nothing behaviour


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can be assessed by the "diet mind-set". E.g. "I am either on diet or off diet", "I will be 100% compliant when I'm on the diet, but will eat as much as possible when I am not on diet". This all-or-nothing thinking is also applied to other areas of the person's life.

The negative effects of dieting and the media play a prevalent role in poor self-esteem, the lack of confidence, a poor and/or distorted body image, as well as obsessions with food. On is constantly bombarded with new fad diets or emaciated looking models. The average woman tries to model herself on this and loses touch with how she wants to look and what is realistic for her size and shape.

Emotions: This is a bit of a chicken and an egg situation. Is the emotion that is being expressed a result of the problem, or the cause of the problem? What comes first, the cause or the effect? Was this person anxious, frustrated, bored, etc before they started having an eating disorder or has the emotion been exacerbated by the eating disorder?

All emotions may contribute to, or be the result of the eating disorder. For example, depression, anger, boredom, emptiness, loneliness feeling, devalued, helpless, inadequate, stressed, frightened etc. may cause or be the consequence of the eating disorder. These emotions need to be controlled and because the person with an eating disorder does not have the coping skills, s/he resorts to the eating disorder pattern. Emotions that are not dealt with are shut off, but do not go away. They come back when you least want them or expect them to. Food or purging or exercise is merely a comforter which restores the equilibrium. Food is also a tool for expressing emotions or feelings as a reward or punishment. For people with an eating disorder, food does not equal food. Food is not eaten for sustenance. Food is a comforter, a friend or a dummy. In summary, their relationship with food is quite abnormal.

Low Energy Expenditure: Obesity is greater among children and

adolescents who frequently watch television (Dietz & Gortmaker, 1985), not only

because little energy is expended while viewing but also because of concurrent

consumption of high calorie snacks. It is widely accepted that widespread physical

inactivity plays a role in the current high prevalence of excess weight. Active

individuals require more calories than less active ones to maintain their weight.

Additionally, physical activity tends to decrease appetite in obese individuals while


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increasing the body's ability to preferentially metabolize fat as an energy source.

Much of the increase in obesity in the last 20 years is thought to have resulted from

the decreased level of daily physical activity. Physical activity, or exercise, both

prevent and reverse obesity. Included in the broad category of television watching

are watching the videotapes; playing on the computer, including text messaging and

computer games on stand-alone game consoles. Television-watching is the number

one leisure-time activity of most school-aged children. In North America it was

found that children aged 8-18 spend about 45 hours per week on media-related

activities. The average high school graduate will likely spend 15000 to 18000 hours

in front of television, but only 12000 hours in school (Welch, 2008). Increased

television viewing causes them in reduction of physical activity, and the subsequent

lack of exercise affect children adversely in many areas. For example, early

childhood is a time of tremendous growth for children and amount of physical

activity positively affects the strength and amount of bone mass; lack of physical

activity leads to diminished bone mass. Metabolic rates during television viewing

are significantly lower than during resting period, including sleep, for both obese

and normal children aged 8-12. Increased health risks are associated with increased

obesity and disorders formerly seen only in adults are appearing more frequently in

younger and younger individuals, Such as type-2 diabetes and hypertension. So

children are not only at risk of developing these diseases as adults, but they are also

more likely to develop them as children. Children who watch less television and play

fewer video games show a significant reduction in measures of obesity, such as

body mass index. In addition to physical inactivity associated with watching

television, there are other reasons why watching television may be linked with

childhood obesity. When watching television, children often mindlessly eat

high-calorie or high-fat snack foods, which also lead to increased weight gain.

Another factor promoting eating in front of the television in general is associated

with commercials for all kinds of food (Welch, 2008).

Illness. Although not as common as many believe, there are some


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illnesses that can cause obesity. These include hormone problems such as hypothyroidism (poorly acting thyroid slows metabolism), depression, and some rare diseases of the brain that can lead to overeating. The control of food intake (how much you eat and how much it takes for you to feel full) and food metabolism (how you convert food to energy) appears to be regulated, at least in part, by a system of hormones produced by cells of the nervous system. The interaction between these “neurohormones” is currently the subject of intense study and compounds that affect these hormones are the focus of a billion dollar diet drug industry. It might not be surprising that the actions of hormones produced in the brain contribute to obesity, but another link to obesity may surprise you, since the source isn't human. It's a virus called adenovirus-36 or “Ad-36.” Ad-36 is a member of a family of about 50 DNA viruses that are associated with some very familiar illnesses ranging from the common cold to pink eye (Womble, Wang, and Wadden, 2002). To see if the virus has a causal connection to obesity, researchers have taken the virus and experimentally infected monkeys with it. The infected monkeys gained significant weight (Hirsch, 1995). Surprisingly, serum cholesterol was lowered in these animals. While these studies suggest a link between the Ad-36 virus and obesity, questions remain - like how does the virus contribute to obesity? In a recent study scientists at Louisiana State University took samples of tissue from individuals who had liposuction and removed adult stem cells from the samples. Stem cells are cells that have the potential to turn into more specialized cells. When infected by the Ad-36 virus, greater than 50% of the cells turned into fat cells, while only a small number of non-infected cells turned into fat cells. The virus-infected fat cells were also bigger than typical fat cells, seemingly capable of storing more fat (Hirsch, 1995). Because the causes of obesity are complex, no one treatment method may be a cure-all. However, interesting avenues of research identified by the Louisiana State study include the possibility of creating vaccines or drugs that target particular genes of the adenoviruses linked to obesity. Understanding the reason why some people infected with Ad-36 aren't obese and why Ad-36 infection is associated with lower cholesterol may be just as interesting (Stunkard and Sobal, 1995).

Other factors: There are many other factors which influence adolescent

food behavior and dietary practices. Food behavior is a response to stimuli.


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Mechanisms that form the foundation of the eating process are located in the

hypothalamus of the brain, where the centers for hunger and satiety are located.

Obesity was thought to be a misinterpretation of eating cues, external or internal.

External stimuli include the appearance, smell, and taste of food. With internal

stimuli, sensations perceived as hunger or satiation exists. These cues play an

important part in eating behavior but don't necessarily cause obesity.

Two types of eating behavior are restrained eaters and unrestrained

eaters. Restrained eaters limit their food intake below complete satiation or

feeling of fullness. Unrestrained eaters eat to the point of complete satiation.

Young children are usually unrestrained eaters and by adolescence they are

forced to control what they eat however fear and boredom often stimulate

eating in adolescents. If this eating is not controlled, it can become

uncontrollable and fat begins to accumulate.

Obese teenagers often have disturbed patterns of eating. Some of the common ones are listed below:

? Consumption of an imbalance of high-energy and low nutrient foods,

over low-energy and high nutrient foods, i.e. eating a donut rather

than a piece of fruit.

? Interpretation of diverse feelings of situations as reasons to eat.

? Susceptibility to eating cues unrelated to physiological needs.

? Guilt related to eating under any circumstances.

? Lack of understanding of bodily needs for nourishment.

? Unwillingness to eat with others, including family members.

? Lack of structure in eating patterns.

Lack of sociability connected with eating patter.

Night eating.


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Binge eating.

Eating only in the latter part of the day after starvation in the early part.

Nausea described as connected with eating in the early part of the day.

Lack of any feeling of control over their food intake.

Eating rapidly and indiscriminately.

(Mahan and Pees, 1984).

Media: The media is a powerful influence on adolescent eating behaviors.

Adolescents watch approximately three and one half hours of television daily

(Mahan and Pees, 1984). A sedentary life-style begins to emerge with hours spent

on watching television rather than on physical activities. Adolescents consume large

quantities of junk food while enjoying TV and commercials tend to stimulate

snacking. Overweight adolescents tend to eat more in response to these

commercials. Commercials use slim, attractive people who eat high-calorie foods

and still look great. These messages condone and encourage eating these foods.

Television characters eat, drink and talk about food on an average of nine times an

hour. Adolescents are prone to weight connected lethargy. This is a vicious cycle in

which overweight adolescents expect rejection by their peers. They want to do less

outdoors and end up spending more time indoors, usually watching television and

being exposed to food (Goulart, 1985).

Peer Influence: Another influence on eating behavior is peer pressure.

Adolescence is a time for socializing, and it is not uncommon for teens to spend

time together eating. Fast-food restaurants are a common “hang-out” place for

teens. The meals associated with these “hang-outs” are high in calories, fat and

sodium. The typical fast-food meal, burger, fries, soda and pizza contain

approximately 900-1300 calorie. In studies conducted on a group of twelve to


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eighteen year olds it was noted that the majority included milk, ice-cream, steak,

roast beef, hamburgers, pork chops, ham, chicken, turkey, orange juice, french fries,

bread, cake and pie as an integral part of their diet. These foods were favored over

foods containing high sources of vitamin A such as liver, squash and spinach which

are considered to be distasteful among those teenagers studied (Schorr and Sanjur,

1972). Results of researches have pointed out that obesity can be "socially

contagious", meaning that people tend to eat as their friends and family do. When

friends and family become obese, their companions tend to follow suit. Researchers

found that a person had an increased chance of becoming obese if their social

network was obese. The risk increased 57% if a friend was obese, 40% if a sibling

was obese and 37% if a spouse was obese. (Christakis and Fowler, 2004)Not only

do friends influence each other to become obese, having more that one obese friend

increases the risk even more.

Several other factors like gender, natural weight gain, and the tendency of

people to associate with similar people have also been studied as the obesity has

become a growing health problem. The prevalence of obesity has increased over

recent years from 23% to 31%. While the study did not offer conclusions as the

reason for the social phenomena of social networks influence on weigh gain, there

are some possible explanations. Possible explanations include inactivity in social

networks, food consumption in a group, influence on eating habits, adoption of

similar exercise patterns, adoption of lifestyle behaviors such as smoking and

tolerance for obesity (Patrick, Calfas, Zabinski, and Cella 2004).

The data did not show how obesity spreads through social networks, but

social norms do appear to play a role. The influence appears to be stronger among

same sex pairs, meaning that same sex friends were more likely to influence each

other than spouses (Kuczmarski, Flegal, Campbell and Johnson, 1994). While

friends appeared to influence each other to obesity, the opposite was also true.

Researchers found that when a friend loses weight that their social network may

follow suit (Trest, Kerr, Ward, and Pate, 2001). People can use this information to


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be successful in their efforts to reach normal weight. Friends, siblings and spouses

who agree to convert to healthy lifestyle habits and weight loss diets increase the

chance of weight loss success for all concerned. Forming bonds with people who of

normal weight may help an obese person get a different perspective on weight loss

and encourage them to success. A gym or health club with normal sized people may

provide the healthy motivation a person needs to reach normal weight.

Nutritional Requirements of Adolescents

Nutritional needs vary from individual to individual but basic nutritional

requirements are clearly defined. The caloric requirements for adolescents are

determined by biologic age, opposed to chronologic age. The RDA recommends

2700-2800 k calories for males aged 11-18 and 2100 2200 for females aged

11-18. These calories must be a proper mix of proteins, carbohydrates, fats,

vitamins and minerals. Caloric needs are related to growth rate, basal metabolic rate

and physical activity. Basal metabolic rate is the amount of energy required for the

involuntary work of the brain, heart, muscles and digestive organs.

Proteins are comprised of more than 20 amino acids. Complete

proteins are usually found in animal foods such as meats, eggs and milk.

Incomplete proteins are usually found in vegetable proteins, such as beans

and nuts. Protein is needed for adequate cell growth. Too much protein can

contribute to obesity.

Carbohydrates include all starches and sugars. The sugars are fructose, found in honey, ripe fruits and vegetables; lactose, found in milk; maltose, found in digested starches and sucrose which is commonly known as table sugar. Starches are found in potatoes, peas, beans, nuts and cereal grains. Carbohydrates supply energy to the body.

Fats serve as an insulator in the body. Fats provide a good way to store energy, and are classified as saturated and unsaturated, the difference being that unsaturated fats are liquid at room temperature. Saturated fats, contained in animal foods, contribute to high cholesterol levels.


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Vitamins are needed for energy release and tissue building. Vitamins have specific functions. There is an increased need for vitamins during adolescence. Important vitamins include A, C, D, E, K, Thiamin, Riboflavin, Niacin B1, Folic Acid, B6, Vitamin B12 and Biotin. A well balanced diet usually supplies all necessary vitamins. Vitamin A, found in green and yellow leafy vegetables; folacin, found in dark green leafy vegetables and citrus fruits; and B6 which is found in whole grain cereals, seeds, legumes and potatoes, are found to be insufficient in most adolescents.

Minerals are necessary for muscle contraction, heartbeat control, bone and teeth formation and cell maintenance. Macrominerals are required in substantial amounts and microminerals, or trace minerals, necessary for good health, are needed in small amounts. The examples of macrominerals and their sources are:

Calcium–milk and dairy products; phosphorus–milk, peas, beef, pork, tuna and peanuts; magnesium–seafood, nuts, meats, wheat bran; potassium–oranges, tomatoes, bananas; iron–seafood, iodized salt, eggs, green vegetables, dry beans and nuts; copper–shellfish, organ meats, raisins; zinc–seafood, nuts, meat, eggs; chromium–meats and whole grains; manganese–nuts, legumes, whole grains; selenium–grains and onions;

The iron and calcium requirements are increased during adolescence due to the increase in growth rate.

To maintain a healthy body, adolescents need to eat a variety of foods. Educators must stress the importance of watching the intake of fats and cholesterol, eating fiber filled foods, watching sugar and salt intake and eating adequate starches. It is important to emphasize eating breakfast, a meal often overlooked by adolescents. Breakfast is important because it provides a portion of the nutrient intake for the day. Teenagers and young adults should include the following to ensure a balanced diet:

Recommended number of servings

Serving size

MILK GROUP–4 Servings daily


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1 cup milk, 1 cup yogurt, 1 oz. cheese, 1/2 cup cottage cheese, 1/2 cup ice cream or frozen yogurt

MEAT GROUP–2 Servings daily:

2-3 oz. cooked lean meat, poultry, fish; 1 egg; 1 oz. shellfish; 2 tbsp. peanut butter; 1/4 cup nuts

FRUIT/VEGETABLE GROUP–4 Servings daily:

1/2 cup juice; 1/2 cup fruit, vegetable; 1 med. banana, apple, orange; 1/4 cup dried fruit; 1/2 grapefruit

GRAIN GROUP–4 Servings daily:

1 slice bread, hamburger bun; 1 oz. cold cereal; 1/2 English muffin; 1/2 cup pasta, rice; 1/2 cup cooked cereal; 1 roll, muffin, tortilla.

Assessment of obesity

Obesity is the accumulation of adipose tissue within the body. The degree of adiposity and the distribution of body fat have been consistently correlated with relative risk of adverse health. Originating in the early 20th century with the Metropolitan Insurance Company weight and height for weight tables, assessment techniques now include a variety of methodologies that involve varying levels of accuracy in estimation and measurement of adiposity and body composition. For research purpose, anthropometric measurements are the most practical tools for diagnosing obesity. Broadly anthropometry aims at measurement of weight and measurement of subcutaneous fat. Some commonly used anthropometric indices are given below. Weight as Percent of Reference Weight: In this method the reference weight of a person as appropriate for his/her weight, is referred. The referred weight is then compared with the actual weight of the person. The relative weight in the actual weight expressed as percent of ideal weight. It is the easiest method of quantifying the degree of obesity. Subjects with


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relative weight more than 120 % are usually considered obese (Williams, Campanaro, Squillac, and Bollella; 1997). Relative body weight is the most commonly used criterion to define obesity. The reference body weights and heights from infancy to adolescence are given in the following table:

Table1.1: Reference body weights and heights from infancy to adolescence.

BOYS GIRLSAGE Height

(Cm)

Weight (Kg) Height (Cm)

Weight (Kg)

At birth 3 months 6 months 9 months12 months 18 months 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years11 years 12 years 13 years14 years15 years16 years 17 years18 years

50.5 61.1 67.8 72.3 76.1 82.4 85.6 94.9 102.9 109.9 116.1 121.7 127.0 132.2 137.5 140.0 147.0 153.0 160.0 166.0 171.0 175.0 177.0

3.3 6.0 7.8 9.2 10.2 11.5 12.3 14.6 16.7 18.7 20.7 22.9 25.3 28.1 31.4 32.2 37.0 40.9 47.0 52.6 58.0 62.7 65.0

49.9 60.2 66.6 71.1 75.0 80.9 84.5 93.9 101.6 108.4 114.6 120.6 126.6 132.2 138.3 142.0 148.0 155.0 159.0 161.0 162.0 163.0 164.0

3.2 5.4 7.2 8.6 9.5 10.8 11.8 14.1 16.0 17.7 16.5 21.8 24.8 28.5 32.5 33.7 38.7 44.0 48.0 51.4 53.0 54.0 54.4

Source: National Center for Health Statistics (NCHS) data, Ministry of

Women & Child Development, Government of India. 2007.


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Body Mass Indices:

Body Mass Index (BMI), also known as the Quetelet Index is a measure combining the weight and height of the individual. Body mass index can be calculated by dividing the weight by the square of the height. Although invented in the mid 1800s by Belgian Adolphe Quetelet, BMI is currently used as a simple clinical tool for health care professionals to determine a patient's potential risk for disease and call for intervention. BMI is used to classify individuals into categories. The most common definitions used clinically for BMI categories include underweight (BMI<18.5), Ideal (BMI 18.5-24.9), Overweight (BMI 25-29.5), Obese (BMI 30-34.9) and Morbidly Obese (BMI =35). Thus, determined by the indirect calculation of weight in kilograms to the square of height in meters (kg/m2), BMI is a simple and convenient proxy measure for excess adiposityin clinical settings. Many health-related indices, such as mortality risk, heart disease, high blood pressure, and diabetes, have a graded and continuous correlation with BMI. According to Budd and Falkenstein (2008) three methods are used to determine BMI: the calculation of individual's weight divided by the height in meters squared, the use of several Web-based computation sites, or comparison of published tables that plot BMI as height and weight intersect.

BMI is particularly useful for large population surveys and for screening purposes; however, it may not always categorize individual risk well. Although BMI represents the degree of body fat, it does not distinguish between excess weight due to fat mass and non-fat mass such as muscle, edema, or bone. For example body builders have a low percentage of body fat, but their MBI may be in the overweight range because of their large lean muscle mass. Another limitation of BMI is that the relationship to body fatness for those of different gender, age, and ethnicity has not been firmly established. In a family study of 665 African, American and Caucasian men and women over the age of 17, the relationship of BMI and fat mass was dependent on gender and age, particularly at lower BMI levels. For women, race was also a factor. (Budd & Falkenstein, 1997).

For children and adolescents, there is controversy regarding the definition of normal BMI values due to concerns about possible interference with normal


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growth, self-esteem, and the desire to promote the development of healthy food behaviours and habits. During childhood, BMI changes with growth and development. There are several periods in which sex, growth, and maturation patterns affect muscular gains and account for BMI variation, rather than adiposity. Thus several authorities have developed child BMI levels including the International Obesity Task Force, the British Child Growth Foundation, and the U.S. Centers for disease Control and prevention (CDC). Excess adiposity in children is known to produce a number of comorbidities in childhood as well as increasing the risk for obesity in adulthood. So the American Academy of Pediatrics and U.S> Preventive service Task Force recommend annual screening with the BMI growth charts for children between 24 months and 19 years of age. But in spite of these limitations, the use of BMI is an accepted method of classifying a patient's risk of the mortality and morbidity due to numerous chronic diseases associated with obesity, including hypertension, hypercholesterolemia, and Type 2 diabetes mellitus (T2DM). These conditions are known to predispose individuals to cardiovascular diseases and stroke and may further increase the risk of subsequent mortality. Numerous health risks that are not usually life threatening are also known to be linked to obesity, including sleep apnea, osteoarthritis, gallbladder disease, gastro esophageal reflux disease, respiratory problems, and depression. In women, obesity is associated with higher levels of pregnancy complications, menstrual irregularities, stress incontinence, and hirsutism (hair growth in places where it is minimal or nonexistent). Breast, endometrial, prostrate and colon cancer have also been found to occur more frequently in obese individuals. For all complications, the risk is graded beginning at BMI level of 30 and rises more steeply as BMI increases. (Budd & Falkenstein, 2008). Thus BMI is considered as better index for assessing obesity because it does away with the need for height - weight tables and is not dependent upon type of obesity frame.

Abdominal Fat:

The distribution of body fat has significant health implications. Abdominal, particularly visceral, fat as compared to subcutaneous or retroperitoneal abdominal fat is associated with higher risk of metabolic syndrome and T2DM. Abdominal obesity, as measured by waist circumference (WC), is known to be a


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better predictor of health risk among those of normal weight, overweight, and obese categories than percent measured by DEXA or BMI. Waist circumferences >120 centimeters or 40 inches in men and 88 centimeters or >35 inches in women are associated with increased risk for T2DM, dyslipidemia, hypertension, and cardiovascular diseases. Ct and MRI can accurately measure the amount of visceral fat, but these methods are too expensive for routine work.

Waist circumference coupled with BMI is a better predictor of health risk than BMI alone, except for individuals with BMI>35. In these individuals, the WC provides no additional predictive power as WC is likely to measure above the recommended cutoff. In those with a BMI between 25-34.9, WC is important for assessing obesity disease risk. Monitoring for change over times provides a reference to risk increase or improvement. In older persons, who are likely to have more fat in relation to muscle mass, measurement of WC should be considered even for those of normal weight. In addition to gender and age differences, ethnic differences are seen in abdominal fat and WC association with disease risk; in particular, Asian Americans or those of Asian descent living outside Asia have increased risk at levels below the recommended cutoffs. However, in children and adolescents, there are no established WC parameters for assessment of health risk. Assessing WC has potential for identifying health risk in this population also. In 9 to 11.5 years old boys and girls, significant correlation with WC and fasting insulin, high-density lipoprotein cholesterol (HDL-C), total triglyceride (TG), and C-reactive protein (CRP) have been found (Budd & Falkenstein, 2008).

Skinfold Thickness as a Measure of Body Fat: The measurement of skinfold thickness using specially designated calipers offers a more direct assessment of fatness. Durmin and Womersley(1974) have measured skinfold thickness at 4 sites (Biceps ,Triceps, Surailliac and Subscapular). A trained technician may obtain skinfold measure relatively easily in either a school or clinical setting. The triceps alone, triceps and subscapular, triceps and calf, and calf alone have been used with children and adolescents. When the triceps and calf are used, a sum of skinfolds of 10-25mm is considered optimal for boys, and 16-30mm is optimal for girls (Lohman, 1987). The interpretation of sum of SFT at four sites is as follow: Sum of SFT Interpretation


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Up to 40 mm Upper limit of normal 40 to 59.9 mm Above normal 60 to 79.9mm Define as body weight 110% or more =80mm Define as body weight 120% or more

(Asthana ,1993)

PSYCHO-SOCIAL CORRELATES OF OBESITY

Obesity is generally considered ugly, shameful and disgraceful. One

is usually viewed as self-indulgent and lacking self-discipline and control.

Some obese adolescents exhibit a disturbed body image which encompasses

the inner mental picture of one's body, including emotional feelings and

attitudes. Disturbances in body image are primarily in the area of feelings.

Factors influencing a disturbed body image are age of onset of the obesity,

presence of an emotional disturbance and negative evaluation of the obesity

by important others. Adolescence is the period during which a disturbed body

image was most likely to begin. This negative image is characterized by a

feeling that one's body is grotesque and loathsome and that others view it with

hostility and contempt (Stunkard and Mendelson, 1967). The feelings are

associated with self-consciousness and with impaired social functioning.

Disturbances in body image have a negative effect on daily activities and on

relationships with the opposite sex. Weight reduction does not seem to alleviate

the problem. Obese adolescents have feelings of low self-esteem, social

isolation, feelings of rejection and depression and a strong sense of failure

(Anderson, 2006). Social attitudes towards obesity are negative and usually

result in the adolescent becoming withdrawn and isolated. In studies conducted

it was also found that obese adolescents generally were taller, had advanced

bone age and had entered puberty earlier than non obese adolescents (Gard,


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2005). Nowadays obesity is recognized to be one of the greatest public health

problems worldwide. There is no indication that the huge increase in obesity

seen the last decades is declining. The examination of psychological aspects

of persons with morbid obesity is essential. Identification of the psychological

factors associated with weight loss expands our knowledge about behaviors

which are crucial in order to avoid failures in treatment. Most information on

this is obtained preoperatively. Although there is no single personality type

characteristic of the morbidly obese, they differ from the general population as

their self-esteem and impulse control is lower. They have passive dependent

and passive aggressive personality traits, as well as a trend for somatization

and problem denial. Their thinking is usually dichotomous and catastrophic

(Berg, 1997). Obese patients also show low cooperativeness and fail to see the

self as autonomous and integrated. In the morbidly obese before undergoing

surgical treatment, unusual prevalence of psychopathology, namely depression

and anxiety disorders, is observed (Gard, 2005). They are subject to prejudice

and discrimination and should be treated with concern to help alleviate their

feelings of rejection and guilt. Information on the psychological profile of obese

persons is limited. Future studies are warranted, since there is a pressured

need for these people to built cognitive skills and control their body weight.

The prejudice associated with obesity is intense. Fat people are often

disregarded and subjected to ridicule. Most comments about fatness have negative

consequences. Young people are constantly humiliated and frequently suffer

permanent emotional scars. Fat people become tired of being judged by weight first

and personality second.

SOCIAL STIGMA: One of the most significant consequences of being an overweight or obese child is the stigmatization and discrimination he or she often faces at school, in playgroups and after-school activities, and, at times, in the home. Although, prevalence of obesity in children has increased greatly over the past three decades, the stigma of being overweight or obese has been an enduring part of childhood and adolescence for much longer. This was first brought to light when


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Richardson and his colleagues (1961) set out to look at the stigmatization of handicaps and found that children stigmatized overweight children; the consistently ranked an overweight child as less desirable to befriend than a child with a broken leg, a child in a wheelchair, a child with a hand missing, and a child with a disfigured face. This study and findings has been replicated numerous times since the original 1961 study with children of different ages and varying cultural backgrounds.

Psychologists and sociologists conceptualize stigma as the possession of a trait, either ascribed (from birth, such as race) or achieved (a trait someone acquires later in life). Overweight is a particularly complicated stigma because there is debate as to whether weight is an ascribed, such as from one's genes, or if it is an achieved trait that results from overeating and underexercising. Although researchers generally agreed that it is both an ascribed and achieved trait, meaning that those with a genetic predisposition are more likely to suffer the consequences of overeating and underexercising, the general public tends to blame people for their weight , hence further stigmatizing them. There are numerous consequences for both adults and children who are stigmatized (Jaffe, 2008).

Link and Phelan (2001) conceptualize stigma as a combination of being labeled, stereotyped, and separated from the rest of the society, in addition to losing status, and being a victim of discrimination. Once a person is labeled as "fat", he or she is also stereotyped as being lazy, sloppy, and ugly. This is particularly harmful for children who are in their formative years. Every experience a child has leaves a lasting effect because children are not as adept as compartmentalizing and rationalizing negative experiences as adults are. Moreover, children's self-concepts start to form at a very young age and they inevitably internalize the fat label and the stereotypes with which it is associated. Therefore, their confidence, sociability, and grades often suffer, leading overweight children onto a path of disadvantage and discrimination. In the current socio-cultural milieu fatness is so reviled that obese individual seen to be devalued in virtually all social context. This results in obese persons enduring substantial stigmatization and discrimination. Even though there is a considerable body of literature documenting the stigmatizing effects of obesity.

The stigmatizing experiences was positively associated with depression,


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general psychiatric symptom, and body image disturbance and negatively related to self esteem(Friedman,2002).This stigmatization contributes to poor mental health adjustment.

The stereotypes associated with obesity, or merely being slightly overweight, have always taken mainstream positions. The positions, despite always being present, have not always been consistent. Having excess body fat was once desirable, indicating wealth and plentiful food supplies. Today, however, being overweight is associated with images of laziness and poor self-control. Despite the varying stereotypes, obesity is a medical condition and has some well-established physiological disadvantages that do not change with the changing generations. In many of the earliest human societies, having excessive body fat was highly priced. But the stereotypes of excessive body fat have shifted dramatically into the modern day. With adequate food supplies, having excess body fat is no longer a necessity for survival. Through modern advertising the thin ideal has come into effect. This ideal dictates that lean and trim bodies are more desirable. This new ideal image also brought new stereotypes about body types. These stereotypes, however, have developed without the general knowledge of the metabolic disorders that make obesity a far-reaching condition.

Today, a person having excessive body fat can encounter many disadvantages in society. Many general stereotypes are assigned to obese people, with lazy and incompetent being two of the more common. The stereotypes are in, large part, negative and assigned as a way to explain why a person is fat. For instance, upon first impression, many people assume that an obese individual is lazy, uncontrolled, and unmotivated. Those three characteristics would, in general opinion, explain why and how a person could accumulate a disproportionate amount of body fat. In a less Malicious form, obese individuals may be seen as jolly or funny. Often, an obese person can be assumed that he is less of a person and more of an object of ridicule. He is often labeled as irresponsible, unkempt, and has poor decision-making skills. DISTORTED BODY IMAGE: Childhood obesity has been demonstrated not only impacts the physical health but also the mental health of the affected children and adolescents. The psychological effects of childhood obesity have been well studied over the past several decades. One particular focus of research has been


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the area of body image (or how children view their own bodies in the context of feedback received from their social community and/or environment) and how body image relates to overall health among children with overweight. Such research demonstrates that body image is related to current weight status and other psychological measures. In addition, more recent studies demonstrate that body image can affect the development of healthy weight-related behaviours by children.

Body image has been widely researched in children, particularly among girls, owing to prior concerns about weight related obsessions and dieting behaviours in this population (Huang, 2008).The findings highlight a vulnerable period in childhood where future body image concepts can be affected and modified by social experiences. Similarly, several studies have shown that girls are more likely than boys to exhibit body dissatisfaction.

Body image disturbances are generally defined as negative thoughts and feelings about one's body, but the concept of body image is multidimensional in nature. Body image disturbances generally fall into two categories: body size distortion the individual has an erroneous perception of his/her body size, and body dissatisfaction, which relates to the cognitive and attitudinal aspects of the individual's body image. Body image disturbance receives attention in current research as it has been implicated as a risk factor for eating disorders such as anorexia nervosa and bulimia nervosa and in obesity. In western societies where the "thin body ideal" is pervasive, individuals who are obese, women in particular, are subject to poor body image. The problem worsens; research has found that as the rates of societal pressure to be thin and the prejudice against obese individuals increase so does the rate of obesity itself. Obese individuals tend to suffer a more negative body image than individuals of normal weight and, as a result, may be so preoccupied with their appearance that they avoid social situations because of their weight. Body image has been correlated with psychological distress and depressive disorders. Research with obese indivisuals suggest theses obese man and women experience higher level of major depression and other mood and anxiety disorders than indivisuals of normal weight. Lower levels of self-esteem are also associated with obesity. However, it is not yet clear whether obese individuals in treatment for weight loss would significantly benefit our specifically addressing body image as a


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therapeutic component.

In a study Fenezyn and Szimigiel (2004) assessed the self evaluation of adolescents with simple obesity. External appearance and physical features are of particular importance in adolescent's obesity. They determine the acceptance or rejection by a peer group and the social status within the group and hence can lead to psychological traumas and complexities. Young obese individuals tend to attribute themselves to more socially disapproved features than in the case with non-obese counterparts.

Since body image is an important concept perhaps movement can be made to the other areas of the self concept such as family, social, identity and personal concepts of selfhood (Sten,1987).Those who were more dissatisfied with their body shape had high depressive score(Al-Subare,2001).The literature is replete with evidence of body image distortion in obesity. Among the factors contributing to this distortion are age of onset, presence of emotional disturbances, and negative evaluation of the obese person by significant others (Wineman, 1980).

PERSONALITY CHARACTERISTICS: Number of researches has examined the personality characteristics associated with obesity. The obese often experience social and psychological difficulties such as feeling of considerable social anxiety, alienation, low self work, and behavioural immaturity (Carddock, 1973). Nappa and Hallistron (1981) suggested that there was a positive relation between mental illness, depth of depression and weight gain .Overweight subjects showed greater emotional reactivity more self dissatisfied (Hudson and Williams, 1981). Klesgas (1984) conducted a study to examine the personality dimension which may discriminate obese and non -obese .The results showed that overweight patients demonstrated elevated depression and self consciousness and lowered assertiveness. Williamson (1985) examined the psychopathology of eating disorders and supported the findings that obese were more neurotic and impulsive.

Self-esteem: A close relationship has been demonstrated between weight and self-worth or self-esteem in childhood and adolescence, although the exact relationship is still unclear. (Finkelson & Black, 2008).Drive for fitness and societal pressure to achieve the ideal but unrealistic body size have reportedly been extended to children as young as 8 years old. Such pressures have caused anxiety


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regarding the body weight in children and adolescents and may influence them to base self-worth on their weight. Factors such as weight that influence self-esteem have been found to be critical contributors to a child's all round development. High self-esteem may be an indicator of outcomes like occupational success, social relationships, well-being, positive perceptions by peers, academic achievements, and improved coping skills. Conversely, low elf-esteem is associated with elevated levels of loneliness, sadness, nervousness, and increased likelihood of initiating in high-risk behaviours such as smoking, sexual promiscuity, and alcohol consumption. With rapid increase in childhood obesity, it is especially important to understand the psychosocial effects of weight on children. Many overweight children and adolescents are believed to be at particularly high risk for developing lower self-esteem and consequently the associated developmental risks.

Findings regarding the association between the presence of childhood obesity and decreased levels of self-esteem vary between studies. The relationship between weight and self-esteem is most consistently reported when body esteem or body image are specifically measured as the primary aspect of self-esteem (Biro, 2005). Many professionals contend that weight additionally affects overall self-esteem as children with lower body image generally report lower global self-esteem. The causality of the relationship between weight and self-esteem also remains undetermined.

Negative attitudes toward overweight children, the pressure to be thin and high levels of peer teasing and rejection that can accompany obesity may lower self-evaluation putting overweight children at a higher risk for developing significantly low levels of self-esteem. Other factors associated with obesity, such as decreased levels of physical activity, increased level of depression, or poor home environments may also be responsible for lower self-esteem levels in overweight/obese children and adolescents.

Anxiety: Fear, worry and apprehension are a combination of emotions that are often defined as anxiety. Anxiety symptoms are heart palpitations, nausea, chest pain, shortness of breath, or tension and headache. The other common symptoms of anxiety are increased blood pressure, heart rate, sweating, and blood flow; inhibited immune and digestive systems; thyroid, respiratory and gastrointestinal disturbances; arthritis; migraine; and allergic conditions. Pale skin, sweating,


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trembling, and pupillary dilation are outward signs of anxiety. Obese people have a 25 percent increased risk for developing anxiety disorder (Juturu and Sriramoju, 2008). Severe anxiety leads to generalized anxiety disorder. It was estimated that about 18 percent adults age 18 years and older exhibit symptoms of anxiety disorder (Regier, 1998). Anxiety disorders last at least 6 months and commonly occur along with other mental and physical illness, including alcohol and substance abuse, which may mask anxiety symptoms or make them worse. Social anxiety disorder or social phobia is the most common anxiety disorder among adults. People with social anxiety disorder have an intense, persistent, and chronic fear of being watched and judged by others and doing things that will embarrass them. Girls and boys are equally likely to develop the disorder, which usually begins in childhood or early adolescence. There is some evidence that genetic factors are involved. Social phobia is often accompanied by other anxiety disorders or depression, and substance abuse may develop if people try to self-mediate their anxiety. In a study, Ryden and Johnson (1990) found that obesity tended to occur in subject with elevated levels of anxiety, tension, impulsiveness and aggressiveness.

Depression: Depression is one of the most common complications of chronic illness. It is estimated that up to one-third of individuals with a serious medical condition experience symptoms of depression. The rate for depression occurring with other medical illness is quite high. Weight gain is a reported side effect of nearly to all antidepressant medications. Tricyclic antidepressant and monoamine oxidase inhibitors are more likely to be associated with weight gain. Improvement in appetite is associated with improved mood may also result in body weight

Epidemiologic data suggest an association between obesity and depression. Extreme obesity was associated with the increased risk for depression across gender and racial groups, even after controlling for chronic physical disease, familial depression, and demographic risk factors (Dong, Sanchez, and Price, 2004). Adult obesity has been associated with depression, especially in women. Studies have also suggested an association between depression in adolescence and higher body mass index in adulthood (Goodman and Whitaker, 2002).


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Whether depression leads to obesity or obesity causes depression is not clear. Obesity and depression are two major diseases which are associated with many other health problems such as hypertension, dyslipidemia, and diabetes mellitus, coronary heart disease, stroke, and myocardial infarction, heart failure in patients with systolic hypertension, low bone mineral density, and increased mortality. Goodman and Whitaker showed that depressed adolescents are at increased risk for the development and persistence of obesity later in their life and Pine et. al. (2001) concluded that depression in childhood is positively associated with BMI during adulthood. In spite of the inconsistent findings overall it is believed that psychological distress caused by obesity may lead to depression. Serotonin is believed to be involved in complex process of integrating physiological and behavioural systems geared towards energy balance. An insufficient serotoninergic neural function in the central nervous system has been shown in many studies to occur in patients with depression. The Third National Health and Nutrition Examination Survey (1988-94) findings suggest that obesity is associated with depression mainly among persons with severe obesity. In a recent prospective study (Goodman and Whitaker, 2006), childhood depression was found to be associated with an increase body mass index in adulthood. Chronic stress is also believed to increase abdominal obesity and its related adverse metabolic consequences, such as hypertension, insulin resistance, and dyslipidemia. This may lead to changes in brain morphology and neuroendocrine axis that can cause both obesity and depression. Obesity in adolescence may be associated with later depression in young adulthood, abdominal obesity among male subjects may closely related to concomitant depression, and being overweight/obese both in adolescence and adulthood may be a risk of depression among female subjects. Anxiety disorders and depression were associated with higher BMI in females, whereas these disorders in males were not associated with higher BMIs. Depression is ten times more frequent in obese patients undergoing obesity treatment vs. general population (Herva et.al., 2006). The following six basic factors were found in obese (a) Neurotic( b) Alcohol dependence (c) Psychological discomfort (d) Dependent (e) Histrionic-Narcissistic-Antisocial (Maceas and Vaz -Leal,2003).

Berg, Simonsson and Ringgvist (2005) compared the life style and health


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aspects among obese and non obese adolescent. Obese boys had a significantly more negative outcome. A large proportion of obese boys reported that they did not like schools, were more absent from school, had been exposed to more violence, more somatic and psychological symptoms ,suicidal thoughts and attempts .Overweight adolescent girls were more prone to high level of anxiety and decline in adjustment (Sharma ,2005). In a recent study Barnow, Bernheim, Schroder, Lauffer,Fush and Freyberger (2005) reported that an overcautious approach represented by some researches is that to dismiss psychological distress and obesity as related in premature .Further research is needed to investigate it.

Treatment of obesity

Today, childhood obesity has become a real issue. More children are

becoming dangerously overweight at an earlier age than ever before. Obesity brings

with it the threat of numerous diseases, ranging from bone and joint problems to

asthma and type 2 diabetes (Foster and Makris, 2004). Once a child begins to lose

weight, these health problems seriously lessen or, in some cases, go away

altogether.

One side effect of obesity that is scarcely acknowledged or dwelled upon are the psychological effects that come with it. Studies have recently established that even if a child manages to lose weight in adulthood, some of the psychological damage from being an obese child linger. Obese children tend to have low self esteem and less confidence in social situations than their peers (Foster, Wadden, Phelan, Sarwer, and Sanderson, 2000). Sometimes they will even try to avoid gym class out of shame for their appearance.

While obese children generally tend to have poor body images, this is not helped by all the teasing that they tend to have to endure at school and in other social situations with their peers. A lot of times, obese children will skip school or drop out altogether in order to avoid having to confront their peers' teasing head on.

This is why drug and alcohol use among overweight teenagers has also risen in recent years. Illicit substances have become an unfortunate way of escaping from and coping with the problem of obesity. Substance abuse problems also contribute


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to increasing the amount of depression an obese child suffers.

There are some things a parent can do to help lessen the psychological stress that results from obesity. For one thing, the subject of overeating should be brought up. Oftentimes, a child will overeat because they are depressed. Once this problem is brought out in to the open, it can be easier to find strategies for coping with it – not to mention alternative approaches to solving depression.

The best treatment for obesity in adolescents is one which provides realistic goals. When setting these goals, it is important to consider many factors, including age, motivation, emotional stability, hereditary body build, extent of overweight or obesity, attitudes towards food, home life and physiological state. A realistic goal for weight loss is slow, averaging 1 to 2 lbs. per week. The importance of a balanced diet must be emphasized. There needs to be a proper mix from all food groups. It is important to eat at least three meals a day, choose foods that have fewer calories, eat smaller portions, cut the intake of fats, alcohol, sugars and limit starches. Fat intake should be 30% (or less) of the total daily calories, carbohydrates 58% and proteins 12%. Calorie levels for obese adolescents should be approximately 1500–1800 k calories. Suggested food substitutions should be done (Wadden and Foster, 2000).

A structured physical activity program must be combined with dieting. Exercise is crucial both in weight reduction and maintenance. Besides providing a positive emotional outlet and a general sense of well being, exercise is a way to have a more attractive, toned body. Walking up the stairs instead of using an elevator, walking rather than driving or taking the bus are some routine activities that can increase physical activity by changing regular patterns. Obese teenagers generally do not like gym classes in school. Motivational techniques must be utilized by educators and parents to promote student participation in such physical activities. Combined support is missing in inner-city districts. Swimming is considered to be an ideal first exercise for overweight children. Playing ball (softball, kickball) is also a good activity. Gymnastics provide an opportunity to develop flexibility and strength. Exercise promotes the development of socialization skills, provides time away from food, decreases appetite, increases absorption of calories and improves physical and mental health.

To achieve weight loss adolescents must want to lose weight and must have adequate support. Diet and exercise should promote a change in behavior, attitudes


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and life-style, through behavior modification programs. These programs encourage changing the pace, times and location of consumption of food. Some recommended suggestions for modifying eating behavior are: to eat all meals at the table, do not read or watch TV while eating, take only the amount you intend to eat to the table, do not feel you must finish everything on your plate if you feel you've had enough, do not take second portions, measure portions, drink a glass of water before each meal, eat three meals a day and reward yourself realistically. Alternative techniques for combating stress, boredom and fatigue, rather than eating food are encouraged while maintaining a food diary. This diary should include information about time spent eating, hunger rating, mood, circumstances, food consumed and quantity. Through constant monitoring of the food diary, eating behavior can be changed (Foster, Wadden, Vogt, and Brewer

With adolescents a multidisciplinary approach must be used when dealing with obesity. The nurturing and care levels associated with childhood must be continued throughout adolescence. What's more, parents can talk to their children about personal appearance and how they feel about themselves. Physical beauty is often dwelled on in this society to an unhealthy degree. What ever happened to inner beauty? Highlight the qualities that make your child special – different, and thus more attractive to others.

What's more, one should make it a habit to praise his/her children whenever they accomplish something positive. Do this often. When dealing with obesity in the family; one should never use food as the basis of reward. When the child accomplishes something worth celebrating, go to a movie rather than splurge on fast food or a night of eating.

Children should never be criticized for not losing weight or accomplishing personal goals. Instead, the parent should always be constructive. Talk it out and find a solution.

Parents should also serve a good example for their kids. That means that the whole family should eat healthy and engage in physical activity as a unit. If you as a parent are not healthy on a mental and physical level, then you cannot expect your children to be, either.

The mental health effects of obesity can be as damaging to the health as the physical effects, according to recent obesity research. Mental health struggles


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caused by being overweight include social discrimination, low self-esteem, and even suicide.

Obesity treatment programs for adolescents rarely have weight loss as a

goal. Rather, the aim is to slow or halt weight gain so that adolescent will grow into

his- her body weight over a period of months or years. Dietz (1983) estimates that

every 20% excess of body weight, the child will need one and half years of weight

maintenance to attain ideal weight.

The best treatment for obesity in adolescents is one which provides realistic goals. When settings these goals, it is important to consider many factors , including age, motivation, emotional stability, heredity, attitude towards food, home life and physiological state . A realistic goal is slow. In a study, Roehling (1999) found that diet counselling with physiological support had a significant impact on depressive symptoms of obese individual. Nauta, Hospess and Jansen (2001) compared that effectiveness of cognitive and behavioral treatment of obese patients. Both the treatment had markedly positive and lasting impact on psychological well - being (concern about shape, weight, self - esteem and depression). Cognitive treatment was not superior to the behavioral treatment. Current treatment of childhood obesity focuses primarily on increasing physical activity, modifying diet, providing nutritional education and teaching self monitoring and stimulus control procedure. A cognitive - behavior, non - diet, healthy life style approach is promising treatment option for childhood and adolescent obesity (Braet, Tanghe, Decalttwe, Moens & Rosseel, 2004).

A combination of cognitive behaviour therapy, nutritional education and physical education programme was found most effective in obesity treatment. Depression and anxiety scores decreased significantly (Fossati, Amati, Painot, Reiner, Haenni & Golay, 2004).

Cognitive Behaviour Therapy:

Cgnitive Behavoural Therapy or Cognitive Behaviour Therapy, (CBT) is an umbrella-term for goal-oriented psychotherapeutic systems that


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aim to influence problematic emotions, behaviors and cognitions. CBT can be seen as a general term for many different therapies that share some common elements and theoretical underpinnings.

CBT is an empirically based, cost-effective psychotherapy for many psychological problems. It is used in individual therapy as well as group settings, and the techniques are also commonly adapted for self-help manuals. Some CBT therapies are more oriented towards cognitive interventions, and some are more behaviorally aligned.

One of the objectives of CBT typically is to identify and monitor thoughts, assumptions, beliefs and behaviors that are related and accompanied to debilitating negative emotions and to identify those which are dysfunctional, inaccurate, or simply unhelpful. This is done in an effort to replace or transcend them with more realistic and useful ones. CBT was primarily developed out of behavior therapy, cognitive therapy and rational emotive behavior therapy and has become widely used to treat various kinds of psychopathology, including mood disorders and anxiety disorders and has many clinical and non-clinical applications.

CBT has proven in scientific studies to be effective for a wide variety of problems, including mood disorders, anxiety disorders, personality disorders, eating disorders, substance abuse disorders, and psychotic disorders. It has been clinically demonstrated in over 400 studies to be effective for many psychiatric disorders and medical problems for both children and adolescents (Rachman, 1997). It has been recommended in the UK by the National Institute for Health and Clinical Excellence as a treatment of choice for a number of mental health difficulties, including post-traumatic stress disorder, OCD bulimia nervosa and clinical depression. There is good evidence for CBT's effectiveness in reducing symptoms and preventing relapse.

Cognitive behavioral therapy most closely allies with the –scientist–practitioner model, in which clinical practice and research is informed by a scientific perspective, clear operationalization of the problem, an emphasis on measurement (and measurable changes in cognition and behavior) and measurable goal-attainment.


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Mary Cover Jones has been called "the mother of behavior therapy By Wolpe (1958) for her early work (1924) on the unlearning of fears in children. However, it was during the period 1950 to 1970 that the field really emerged, with researchers in the United States and the United Kingdom who were inspired by the behaviorist learning theory of Ivan Pavlov, John B. Watson and Clark L. Hull (Rachman, 1997). In Britain, this work was mostly focused on the neurotic disorders through the work of Joseph Wolpe, who applied the findings of animal experiments to his method of systematic desensitization, the precursor to today's fear reduction techniques. British psychologist Hans Eysenck (1960) inspired by the writings of Karl Popper, critizised psychoanalysis in arguing that "if you get rid of the symptoms, you get rid of the neurosis", and presented behavior therapy as a constructive alternative. In the United States, psychologists were applying the radical behaviorism of B. F. Skinner to clinical use. Much of this work was concentrated towards severe, chronic psychiatric disorders, such as psychotic behavior and autism.

Although the early behavioral approaches were successful in the neurotic

disorders, it had little success in treating depression (Rachman, 1997). Behaviorism

was also losing in popularity due to the so-called "cognitive revolution". The

therapeutic approaches of Aaron T. Beck and Albert Ellis gained popularity among

behavior therapists, despite the earlier rejection of "mentalistic" concepts like

thoughts. Both included behavioral elements and concentrated of problems in the

present. Ellis' system, developed in the early 1950s, was called rational therapy, and

can arguably be called one of the first forms of "cognitive behavioral therapy". It was

partly founded as a reaction against popular psychotherapeutic theories at the time,

mainly psychoanalysis (Ellis1975). Aaron T. Beck, inspired by Ellis, developed

cognitive therapy, in the 1960s. Cognitive therapy rapidly became a favorite

intervention to study in psychotherapy research in academic settings. In initial

studies, it was often contrasted with behavioral treatments to see which was most

effective. In recent years, however, cognitive and behavioral techniques have often

been combined into cognitive behavioral treatment. This is arguably the primary type

of psychological treatment being studied in research today.


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Concurrently with the contributions of Ellis and Beck, starting in the

late 1950s and continuing through the 1970s, Lazarus (1958) developed what

was arguably the first form of "broad-spectrum" cognitive behavioral therapy.

He later broadened the focus of behavioral treatment to incorporate cognitive

aspects (1971). When it became clear that optimizing therapy's effectiveness

and effecting durable treatment outcomes often required transcending more

narrowly focused cognitive and behavioral methods. Arnold Lazarus expanded

the scope of CBT to include physical sensations (as distinct from emotional

states), visual images (as distinct from language-based thinking), interpersonal

relationships, and biological factors.

The particular therapeutic techniques vary within the different approaches of CBT according to the particular kind of problem issues, but commonly may include keeping a diary of significant events and associated feelings, thoughts and behaviors; questioning and testing cognitions, assumptions, evaluations and beliefs that might be unhelpful and unrealistic; gradually facing activities which may have been avoided; and trying out new ways of behaving and reacting. Relaxation, mindfulness and distraction techniques are also commonly included. Cognitive behavioral therapy is often used in conjunction with mood stabilizing medications to treat conditions like bipolar disorder. Cognitive behavioral therapy generally is not an overnight process. Even after patients have learned to recognize when and where their mental processes go awry, it can take months of effort to replace a dysfunctional cognitive-affective-behavioral process or habit with a more reasonable and adaptive onpecific applications

CBT is applied to large amount of clinical and non-clinical conditions and has been successfully used to the treatments of many clinical disorders, personality conditions and behavioral problems.The use of CBT has been extended to children and adolescents with good results. It is often used to treat depression, anxiety disorders, and symptoms related to trauma and Post Traumatic Stress Disorder. Significant work has been done in this area by Mark Reinecke and his colleagues at Northwestern University in the Clinical Psychology program in Chicago. Paula Barrett and her colleagues have also validated CBT as effective in a group setting for the treatment of youth and


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child anxiety using the Friends Program she authored. This CBT program has been recognized as best practice for the treatment of anxiety in children by the World Health Organization.Combining the Biofeedback method with the CBT process is very effective. CBT has been used with children and adolescents to treat a variety of conditions with good success. CBT is also used as a treatment modality for children who have experienced complex post traumatic stress disorder, chronic maltreatment, and post traumatic stress disorder.

AIM AND IMPORTANCE OF THE PRESENT STUDY

Historically, a fat child means a healthy child, one who is likely to

survive the rigors of under nourishment and infection. But unlike the past,

today obesity or over weight in childhood is considered as a major health risk

condition developed mainly due to malnutrition and improper lifestyle and

which can lead to a number of health problems both in childhood and later in

adulthood. According to Swaminathan (2005) a person whose body weight is

higher than normal by 15-20 percent is considered as overweight and by 25

percent is considered as obese. A child is considered as obese when the total

body weight is more than 25 percent fat in boys and 32 percent in girls.

Overweight is associated with the onset of major chronic diseases leading to complications and also psychosocial problems in children and adults. The greater concern is that the risks of overweight during childhood will persist into adolescence and adulthood. Tackling the problems of the growing numbers of overweight individuals is a major challenge for most countries. Hence close monitoring of overweight prevalence in children and adolescents and taking timely preventive measures will be an effective approach in dealing with the problem of obesity.

During the past two decades, the prevalence of obesity in children has risen greatly worldwide and this excessive fatness has arguably become a major health problem of both developed and developing countries. Overweight and obesity during childhood is a matter of growing concern in India also. Most individuals develop their eating and activity patterns during childhood. The


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transition in nutrition and life style by the popularity of fast foods, soft drinks, sedentary life style, lack of exercise, increased television watching and computer use are the common trends adopted by children today. These may be the causes of overweight seen in children of both rural and urban areas.

As it has been discussed that and obesity and its health consequences have been recognized as major public health problems worldwide. A significant increasing trend in the prevalence of overweight and obesity among children and adolescents has been documented over the last few decades in developed and in developing countries (Chinn & Rona, 1974; Martorell, Kettel & Hughes, 2000).The most significant long-term consequences of childhood and adolescent overweight and obesity are their persistence into adulthood with all of the attendant health risks (Must & Strauss, 1999; power, lake cole, 1999), such as dyslipidemia, hyperinsulinemia, type 2 diabetes, hypertension, cardiovascular diseases (Freedman, Dietz, Srinivasan & Berenson, 1999), arthritis, and behavioral problems. Obesity in children and adolescents is gradually becoming a major public health problem in many developing countries, including India (Popkin & Doak, 1998). The prevalence is higher in urban than in rural areas (Kaur,Kapil & Singh, 2005). The results of studies among adolescents from parts of Punjab, Maharashtra, Delhi, and South India revealed that the prevalence of overweight and obesity was high (11% to 29% ) (Kaur,Kapil & Singh, 2005). In Ludhiana, Punjab, urban children in the age group of 11 to 17 years of age were more overweight (11.6% ) than their rural counterparts (4.7% ) (Kaur,Kapil & Singh, 2005). In Pune, Maharashtra, studies among 1228 boys in the age group of 10 to 15 years indicated that 20% were overweight, whereas 5.7% were obese (Kaur,Kapil & Singh, 2005). A study carried out in Ludhiana, Punjab, on school children in the age group of 9 to 15 years revealed that the overall prevalences of overweight and obesity were 11% and 14% , respectively (Kaur,Kapil & Singh, 2005). Another study carried out in Delhi, India, among 5000 private school children in the age group of 4 to 18 years in 2002 by the Nutrition Foundation of India revealed that the prevalence of overweight was 29% (Kaur,Kapil & Singh, 2005). A similar study conducted in Chennai, in South India, showed that the prevalence of overweight was 17% and of obesity was 3% (Kaur,Kapil & Singh, 2005). In the studies in Punjab, Delhi, and Maharashtra, BMI cut-off points suggested by James et al. (James, Ferro-luzi, & Waterlow, 1988) were used for the definitions of overweight and


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obesity, as well as age- and sex-specific percentiles of BMI (National Health and Nutrition Examination Study), and the subjects involved belonged only to highly affluent families. In the study in South India, the adolescents belonged to high, middle, and low socioeconomic status (SES). The age groups included in these studies varied from one another. Several cross-sectional studies in Western countries have shown that overweight and obese adolescents are less physically active than non-obese subjects, and physical inactivity, high socioeconomic background, and dietary transition were found to be major factors (Eisemann, bartee & wang, 2002). However, in this study, the role of factors such as participation in sports and games, household chores, physical inactivities such as television viewing and playing computer/video games, and consumption of junk foods were also studied.

It has also been discussed that nowadays obesity is recognized to be one of the greatest public health problems worldwide. There is no indication that the huge increase in obesity seen the last decades is declining. The examination of psychological aspects of persons with morbid obesity is essential. Identification of the psychological factors associated with weight loss expands our knowledge about behaviors which are crucial in order to avoid failures in treatment. Most information on this is obtained preoperatively. Although there is no single personality type characteristic of the morbidly obese, they differ from the general population as their self-esteem and impulse control is lower. They have passive dependent and passive aggressive personality traits, as well as a trend for somatization and problem denial. Their thinking is usually dichotomous and catastrophic. Obese patients also show low cooperativeness and fail to see the self as autonomous and integrated. They are subject to prejudice and discrimination and should be treated with concern to help alleviate their feelings of rejection and guilt. Information on the psychological profile of obese persons is limited. Future studies are warranted, since there is a pressured need for these people to built cognitive skills and control their body weight.

Therefore, the presernt study was undertaken to examine the nature and severity of the psycho-social problems associted with obesity amongo adolescent girls. For this purpose obese and non-obese adolescent girls will be compared on introversion-extroversion, self-concept, dependance-independance, temperament, adjustment, and anxiety


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dimensions of personality. Attempt will also be made to find out the difference between obese and non-obese adolescent girls on their levels of adjustment, on their perceived psycho-social climate on home, and also on social anxiety, particularly on social avoidance distress and fear of negative evaluation. A combination of cognitive -behavioural therapy and physical activity programme would also be utilized for the management of morbid obese girls. The integrated management programme would be conducted in diffrent sessions for five to six months duration. At the end of the treatment each subjects of morbid obesity would be assessed on the following measures:

1-Body mass index (BMI)

2-Social anxiety

3-Perceived psycho-social home environment

4-Health and emotional adjustment.

CHAPTER-2


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A STUDY OF PSYCHOLOGICAL ASSESSMENT AND TREATMENT...

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