Higher weight and mental health and wellbeing in childhood

What is this resource about?

This resource aims to improve practitioners’ understanding of the connections between higher weight and mental health in childhood. It provides guidance on how practitioners can support the physical and mental health and wellbeing of children with higher weight.

Please note: this resource does not offer guidance on addressing weight in children.

Who is this resource for?

This resource is for health practitioners working with children experiencing higher weight and their families. This includes:

• general practitioners
• paediatricians
• psychologists
• dietitians
• exercise physiologists/physiotherapists.

On this page:

• How many Australian children experience higher weight?
• Factors contributing to higher weight in childhood

Higher weight in childhood is a complex issue that is emerging as a significant public health challenge. The 21^st century has seen an increase in non-communicable diseases (diseases that can’t be passed from one person to another). As part of this increase, higher weight in childhood has been described as a pandemic with adverse consequences across the globe. Higher weight has been shown to affect both a child’s physical and mental health (AIHW, 2020a; 2020b).

There has been an increased focus on the ways in which chronic physical conditions impact on mental health outcomes, how children feel about themselves and the ways in which they interact with others. While gaps exist in the literature, this resource presents an overview of higher weight in childhood and the mental health outcomes associated with it. The paper aims to increase practitioner knowledge and provide practical guidance to better support the wellbeing of children experiencing higher weight and their families.

How many Australian children experience higher weight?

In Australia in 2017–18, approximately 1 in 4 children aged 2–17 years were considered ‘higher weight’, with 17% classified as ‘overweight’ and 8% ‘obese’ (AIHW, 2020b). Australian research suggests that while children’s weight can fluctuate, higher weight generally increases with age (up to 31% of adolescents aged 16–17 years; AIHW, 2020b).

Children living in low socioeconomic areas, rural and remote regions, as well as those with disability are more likely to experience higher weight (AIHW, 2020a; 2020b). The National Health Survey indicates that 38% of Aboriginal and Torres Strait Islander children and adolescents were of higher weight in 2018–19, increasing from 31% in 2012–13 (AIHW, 2020b).

Factors contributing to higher weight in childhood

Research indicates that a key cause of higher weight is an energy imbalance (i.e. the child consumes more energy through food and drink than they use up through movement and physical activity). But the causes of higher weight are often more complex than this. The following factors all play a part (AIHW, 2020b; Russell-Mayhew, McVey, Bardick & Ireland, 2012):

• Biology (e.g., genetics, gender, physiology, metabolic dysfunction, medications)
• Behaviour (e.g. the amount of physical activity the child participates in, compared to their sedentary behaviour [including screen time] and their quality of sleep).
• Environmental factors, such as socioeconomic status and family context (including household income and parental education level), school-level academic performance, and ability to access parks and green spaces.

Modifiable environmental factors that have been shown to increase the risk of higher weight include (AIHW, 2020b; Weihrauch-Bluher & Wiegand, 2018):

• the accessibility and affordability of unhealthy eating options such as low-nutrient, energy dense foods and sugary drinks
• targeted marketing of calorie-dense and unhealthy food options through the media
• urbanisation and the urban design of communities that reduce physical activity
• increased use of technology, which further encourages sedentary behaviour.

Early experiences in a child’s life can also play a significant role in establishing lifestyle habits. For example, children exposed to less supportive family environments at age one, such as households experiencing family stress and parental mental illness, are more likely to be of a higher weight at 21 years (Smith & Kobayashi, 2020). Home environments characterised by high chronic stress due to family and domestic violence or child maltreatment have also been linked to higher weight (Danese & Tan, 2014; Pizzi & Vroman, 2013).

On this page:

• Health-related quality of life
• Self-esteem
• Anxiety and depression
• Autism spectrum disorder (ASD) and Attention-deficit/hyperactivity disorder (ADHD)
• Disordered eating

While health professionals understand the links between higher weight and physical health conditions, there is less awareness of the relationship between childhood weight and and mental health. Often in addressing higher weight in childhood, the focus is on managing the physical condition and its consequences rather than the mental health impacts.

But children’s physical and mental health cannot be separated. An increased understanding of, and support for, the mental health and wellbeing of children with higher weight will also increase the likelihood of improved physical health outcomes (Pont et al., 2017).

It is important to note that not all children with higher weight experience poor mental health (Pizzi & Vroman, 2013). It is crucial to understand children’s individual circumstances and to assess their level of mental health and wellbeing as you would assess for co-occurring physical conditions.

The relationship between childhood weight and mental health is complex and may differ by age, gender and weight status (e.g. AIHW, 2020b; Lindberg et al., 2020; Sanders et al., 2015; Walker & Hill, 2009). Mental health conditions can contribute to higher weight and vice versa (Russell-Mayhew et al., 2012). For example, symptoms of depression may include decreased motivation for physical activity, increased sedentary behaviour and decreased or increased consumption of food, all of which may affect weight (Pizzi & Vroman, 2013). Finally, children with higher weight are at increased risk of experiencing multiple negative psychosocial or mental health outcomes (Rankin et al., 2016).

The following sections provide brief summaries of the links between higher weight in childhood and commonly reported psychosocial (e.g. health-related quality of life, self-esteem) and mental health (e.g. anxiety, depression, eating disorders) concerns.

Health-related quality of life

A child’s health-related quality of life can be described as ‘a multi-dimensional concept that includes domains related to physical, mental, emotional, and social functioning’ (Office of Disease Prevention and Health Promotion, n.d.).

Children with higher weight report impaired health-related quality of life, particularly in the following domains (O’Connor, Warren & Daraganova, 2017; Rankin et al., 2016; Russell-Mayhew et al., 2012; Sanders et al., 2015):

• Emotional (e.g. felt angry, sad, afraid or scared, or had trouble sleeping).
• Social (e.g. had problems getting along with other children, being teased by other children).
• Physical (e.g. had problems walking more than one block, lifting something heavy).

Self-esteem

Self-esteem influences children’s wellbeing and ability to cope with difficult situations (Hosogi, Okada, Fuji, Noguchi & Watanabe, 2012). Children with higher weight are at increased risk of experiencing lower self-esteem (Moradi et al., 2020; Sikorski et al., 2015), with some research reporting that higher weight predicts low self-esteem (Harriger & Thompson, 2012). The negative relationship seems to strengthen with age, though girls may experience lower self-esteem from a young age (Sanders et al., 2015; Walker & Hill, 2009).

Factors such as teasing from peers, weight-related criticism from parents, as well as beliefs that their weight is beyond their control, rather than weight status itself, may moderate the relationship between higher weight and self-esteem (Harriger & Thompson, 2012).

Anxiety and depression

Mixed findings have been reported in relation to higher weight and anxiety. Several meta-analyses and systematic reviews have reported no association or mixed findings in relation to higher weight and anxiety (Moradi et al., 2020; Sanders et al. 2015). However, a large study comparing children receiving treatment for obesity with children in the general population found increased rates of anxiety in the higher weight group. Rates remained high even when risk factors such as comorbid neuropsychiatric disorders and socioeconomic status were accounted for (Lindberg et al., 2020).

Similarly, certain studies have found little relationship between child weight status and depressive symptoms (e.g. Moradi et al., 2020), while others have shown that higher weight is related to an increased risk of depression (Harriger & Thompson, 2012; Lindberg et al., 2020; Sanders et al., 2015; Sutaria, et al, 2019). Findings on gender have also been mixed (Lindberg, et al., 2020; Sanders, et al., 2015; Sutaria et al., 2019).

Research suggests the relationship between weight and depression may work both ways. Common depressive symptoms such as decreased motivation to participate in activities, increased sedentary behaviour, and medications used to treat depression may affect children’s weight (Pizzi & Vroman, 2013).

These varied findings serve as a reminder of the need to conduct personalised assessments of each child. Doing so ensures that they receive appropriate and individualised support for any mental health concerns.

Disordered eating

Children with higher weight are at increased risk of disordered eating attitudes and behaviours (Harriger & Thompson, 2012; Sanders et al., 2015; Smith & Kobayashi, 2020). Disordered eating is also a risk for higher weight (National Eating Disorders Collaboration, 2011). For example, binge eating has been found to be both a consequence of, and a risk for, obesity (Harriger & Thompson, 2012).

Research has identified a trajectory from weight/shape concerns and dietary restraints through to more extreme weight control behaviours (e.g. binge eating, fasting), leading to an increased risk for eating disorders (McLlelland et al., 2020). Intervening early to identify, assess and support children by focusing on factors that can be modified (e.g. concerns about shape/size) can potentially reduce the risk of children experiencing these poor outcomes.

On this page:

• Weight stigma
• Parental influences on children’s weight and wellbeing

Weight stigma

Weight stigma plays a critical role in negative mental health outcomes for children with higher weight. It is defined as ‘negative weight-related attitudes and beliefs that are manifested through stereotypes, bias, rejection, and prejudice toward children and adolescents because they are overweight or obese’ (Puhl & Latner, 2007, p.558).

Weight stigma is a common experience for children and adolescents. Obesity has been described as ‘the most stigmatising and least socially acceptable condition in childhood’ (Schwimmer et al., 2003, p.1818), with children as young as three years attributing negative adjectives to those with larger body sizes (Harriger & Thompson, 2012).

Children with higher weight commonly experience teasing, bullying and relational victimisation (e.g. social exclusion) from other children about their body, weight and shape (Puhl & Latner, 2007). Australian research has found that children (aged six and 13 years) with higher weight were 4–8 times more likely to be bullied and teased than their ‘normal’ weight peers (Sanders et al., 2015).

Children have reported experiencing stigma not only from other children but also their parents, other family members, teachers, health care professionals and the media (Pont et al., 2017). There may be a misguided belief that inducing stigma and shame (e.g. through weight criticism and a focus on weight reduction) will motivate children to lose weight. In reality, weight stigma is associated with weight gain and plays a role in a range of negative outcomes for children, including (Harriger & Thompson, 2012; Mayhew, et al., 2012; Pont et al., Sanders et al., 2015):

• body dissatisfaction (defined as ‘a negative attitude towards one’s own body resulting from a perceived discrepancy between the actual body image … and the ideal body image’ (Heider, Spruyt & De Houwer, 2018, p.158)
• depressive symptoms
• social isolation
• binge eating
• an avoidance of healthcare settings
• a reduction in physical activity
• and suicidal ideation.

Further, the negative effects of weight-related stigma may have a greater influence on a child’s psychosocial outcomes than their actual weight status (AIHW, 2020b; Harriger & Thompson, 2012).  Adolescents who have experienced weight-related teasing and bullying from family and peers are more likely to report negative psychosocial outcomes, such as reduced health-related quality of life, low self-esteem and depressive symptoms. This is true regardless of the child’s BMI, weight status or weight loss (AIHW, 2020b; Harriger & Thompson, 2012).

Parents of children with higher weight may also experience stigma in relation to their child’s weight, particularly if they are themselves higher weight (Bradbury et al., 2018; Mikhailovich & Morrison, 2007).

Parental influences on children’s weight and wellbeing

Parental weight-related beliefs, attitudes and behaviours can affect children’s wellbeing.  Parents’ views of their children as being overweight, regardless of actual weight status, increase the risk of negative consequences (Robinson, Daly & Sutin, 2020).

Children whose parents identify them as being overweight are more likely to be actively trying to lose weight themselves and to view their body size negatively (Robinson & Sutin, 2017). A limited evidence base suggests that parental encouragement to lose weight and criticism of children’s weight may be particularly detrimental to their wellbeing. For example, it may lead to poorer physical self-perceptions and greater dieting and dysfunctional eating attitudes and behaviours (Gillison et al., 2016).

Children’s reports of their parent’s weight-related behaviours, such as dieting or commenting about weight, have been linked to children’s body dissatisfaction, weight concerns and dieting habits. These factors in turn have been linked to poor mental health outcomes for children (Haines, Neumark-Sztainer, Hannan & Robinson-O’Brien, 2008).

In contrast, parental encouragement of healthy lifestyles without explicit reference to weight is associated with better child wellbeing. Positive parental involvement, such as having conversations about improving health behaviours, may help avoid some of the negative outcomes associated with higher weight in childhood (Gillison et al., 2016).

The family, in particular parents, are also integral to treatment options to address higher weight and mental health concerns in children. Family-based interventions have been found to be effective when addressing the mental health impacts of higher weight (Hart et al., 2015; Diao, Wang, Yang & Li, 2020; Murray et al., 2019).

Body dissatisfaction and concerns about size and shape

Concerns about weight and shape and body dissatisfaction are potentially modifiable risk factors for negative childhood mental health outcomes (Russell-Mayhew et al., 2012). Children with higher weight are significantly more likely to report dissatisfaction with their weight or appearance (Austin, Haines & Veugelers, 2009; Moradi et al., 2020; Tatangelo, McCabe, Mellor & Mealey, 2016). Body dissatisfaction and weight concerns may be evident in children as young as preschool age (Harriger & Thompson, 2012; Tatangelo et al., 2016). Concerns about shape and size have been found to be more predictive of negative psychosocial outcomes than actual weight status (Russell-Mayhew et al., 2012).

Weight stigma plays a key role in the relationship between weight and body dissatisfaction (Harriger & Thompson, 2012). For instance, weight-related teasing or criticism can lead to poor body image or dissatisfaction and disordered eating behaviours, as well as depression and suicidal ideation. In contrast, high body satisfaction (i.e. feeling confident and positive about your body) has been linked to healthy weight related behaviours (Austin et al., 2009).

On this page:

• Consider your own attitudes
• Use non-stigmatising language
• Explore children’s and parents’ needs
• Intervene early
• Information on aspects of healthy lifestyle

You may feel concerned about discussing a child’s weight in relation to their mental health and wellbeing. But many families will want to have these conversations, particularly if they have concerns about their child. It is critical, however, that you can do so in a way that supports families’ efforts and children’s wellbeing.

This section includes a range of practice considerations related to working with families where there is a child experiencing higher weight.

Consider your own attitudes

Healthcare professionals can be a potential source of weight bias and stigma (Pont et al., 2017) and have reported negative attitudes towards patients with higher weight (Mikailovich & Morrison, 2007). The risk of a biased response may increase if parents of children with higher weight are higher weight themselves.

Australian medical professionals have reported that barriers to paediatric weight management include (Mihrshahi, Gow & Baur, 2018).:

• difficulties in raising the issue
• a lack of confidence in providing treatment for people with higher weight
• a lack of referral pathways; and
• a need for further training.

Both weight and mental health can be highly sensitive issues. Parental attitudes and behaviours strongly influence their children’s attitudes and behaviours, and therefore a strong relationship with parents is also essential to supporting children (Bradbury, et al., 2018). If parents feel judged or shamed, they are less likely to engage with, and follow through with, any proposed intervention.

Consider the following strategies:

• Critically reflect on your attitudes and beliefs towards food, weight and health. Consider how your beliefs may be affected by broader cultural and societal attitudes – for example, how websites, games and the mainstream and social media portray diverse body shapes.
• Build a strengths-based therapeutic relationship with families by demonstrating care, warmth and trust (Bradbury et al., 2018; Small & Aplasca, 2016). Parents’ attitudes and behaviours strongly influence their children’s attitudes and behaviours; therefore, a strong relationship with parents is essential to supporting children (Bradbury, et al., 2018). If parents feel judged or shamed, they are less likely to engage with, and follow through with, any proposed intervention.
• Use empathic and empowering counselling techniques, such as motivational interviewing to avoid parents feeling judged or shamed (Pont et al., 2017).

Use non-stigmatising language

Negative attitudes and weight bias may be expressed through language. The way you talk about weight can contribute to families’ feelings of stigma and shame and poor outcomes for children (Bradbury et al., 2016). Simply labelling children by weight category can be stigmatising (Harriger & Thompson, 2012). Research has found that terms such as ‘obese’, ‘weight problem’ and ‘fat’ are linked to feelings of shame, embarrassment and sadness in adolescents, particularly if used by their parents (Pont et al., 2017).

It is important to discuss weight stigma, bullying and teasing with parents, highlighting how their own negative weight-related language may affect their children’s mental health and wellbeing. The research clearly indicates that identifying a child as overweight, focusing on losing weight and weight-related criticism are all linked to poorer mental health outcomes (Harriger & Thompson, 2012; Sanders et al., 2015). But parents may incorrectly believe that focusing on their child’s weight will help to motivate them. Parents may also feel their own shame and stigma, and it may be necessary to work with them to ensure that they do not blame themselves for their child’s weight status.

Consider the following strategies:

• Focus on health rather than weight and use neutral words such as ‘weight’ or ‘body mass index’ rather than ‘obesity’ or ‘fat’.
• If you do need to talk about weight, work with families to understand the language they find acceptable and feel comfortable with (Mihrshahi et al., 2018; Pont et al., 2017).
• Discuss weight stigma, bullying and teasing with parents, highlighting how their own negative weight-related language may impact their children’s wellbeing.
• Work with parents separately to the child, if necessary. They may need to be referred to further supports (e.g. psychologist) for their own concerns, to be able to support their child’s wellbeing.

Explore children’s and parents’ needs

It is important to provide psychoeducation for families, as many parents are unaware of the links between child weight and mental health. Understanding that both weight and mental health can be sensitive issues, it is important to be prepared for a wide range of parental responses, including strong emotions and denial of the concerns (Provvidenza et al., 2017).

Consider the following strategies:

• Talk with parents about the complexity of the issue: for example, the biological, environmental and societal factors that can influence a child’s weight; the potentially bi-directional nature of the relationship between weight and mental health’, and the roles stigma and body concerns may play in mental health difficulties.
• Provide children and parents with clear and simple information, preferably in visual or written formats.
• Work with parents to understand their knowledge and beliefs about weight, health and wellbeing (Mikhailovich & Morrison, 2007). This is especially important when working with families from a cultural background different to your own.
• Consider the family’s specific context (i.e. family stressors, family functioning) and how this may affect their child’s health and wellbeing.
• Explore children’s wishes and goals, along with parents’ hopes for their family and children, and consider who should be involved in any discussions. Depending on their age, capacity and preference, children may wish to be involved in weight-related conversations too. You might also involve other family members or people who provide care for the child (Provvidenza et al., 2017).
• Explore any barriers and readiness for change (Mikhailovich & Morrison, 2007).
• Showing concern, communicating empathy and understanding, and role modelling unbiased language, attitudes and behaviours will support these efforts.

Intervene early

Early intervention mental health strategies can be part of integrated family-based interventions that involve addressing health strategies to the entire family rather than just the child.

Consider the following strategies (adapted from: Austin et al., 2009; Harriger & Thompson, 2012; Pont et al., 2017; Russell-Mayhew et al.,2012; Walker & Hill, 2009):

• Use whole-of-family interventions that have been found to improve quality of life for children. Include a focus on wellbeing (building self-confidence, self-esteem and body image) as part of any intervention (Murray et al., 2019).
• Consider family-based approaches such as (Australian Psychological Society, n.d.; Provvidenza et al., 2017; Small & Aplasca, 2016):
  • coaching
  • motivational interviewing
  • goal setting
  • self-monitoring
  • parenting skills training
  • effective problem solving; and
  • cognitive-behavioural approaches.
• Focus on healthy lifestyle approaches – healthy eating, physical exercise, sleep quality, etc. – rather than the child’s weight. This includes encouraging families to participate in activities they enjoy, as this is more likely to support child wellbeing and sustained behaviour change. The following section includes links to ideas on how to support a healthy lifestyle for children.
• Promote healthy body image and body satisfaction as well as an acceptance of diverse body shapes. This can be supported by:
  • taking the focus off weight
  • identifying and taking steps to prevent child weight and shape concerns, regardless of the child’s weight status; and
  • providing psychoeducation on topics such as healthy lifestyles and factors that affect weight and body diversity.

The following section lists further resources on promoting positive body image.

• Target adult role models, such as parents and teachers, and encourage them to address stigma and display body positive and healthy lifestyle attitudes in their respective environments.

If you have concerns about the mental health and wellbeing of a child with higher weight but are unsure of how to raise them with the family, we have created a resource that offers a step-by-step process to have these conversations. It will support you to work with families in a way that maintains engagement and:

• avoids further stigmatising children
• shifts the focus from weight to healthy living; and
• supports children’s body positivity and self-esteem.

See our Raising child mental health concerns with parents of children with higher weight practice paper for more.

As a healthcare professional, you are well placed to work collaboratively with parents to identify and consider what may be contributing to their child’s mental health concerns. Further, if you are an allied health professional and you have concerns about the mental health of a child with higher weight, you may wish to refer the family to a GP or paediatrician for further assessment and support.

Finally, further practice strategies for supporting the wellbeing of children with higher weight can be found in our Supporting the mental health and wellbeing of children with higher weight online course.

References

Austin, S. B., Haines, J., & Veugelers, P. J. (2009). Body satisfaction and body weight: Gender differences and sociodemographic determinants. BMC Public Health, 9. Doi: 10.1186/1471-2458-9-313.

Australian Institute of Health and Welfare. (2020a). Australia’s children: Overweight and obesity. Cat. no. CWS 69. Canberra: AIHW.

Australian Institute of Health and Welfare. (2020b). Overweight and obesity among Australian children and adolescents. Cat. no. PHE 274. Canberra: AIHW.

Australian Psychological Society. (n.d.). Obesity in childhood.

Bradbury, D., Chisholm, A., Watson, P. M., Bundy, C., Bradbury, N., & Birtwistle, S. (2018). Barriers and facilitators to health care professionals discussing child weight with parents: A meta‐synthesis of qualitative studies. British Journal of Health Psychology, 23 (3), 701–722.

Cortese, S., Moreira-Maia, C. R., St Fleur, D., Morcillo-Peñalver, C., Rohde L. A., & Faraone, S. V. (2016). Association between ADHD and obesity: A systematic review and meta-analysis. The American Journal of Psychiatry, 173(1), 34–43. doi: 10.1176/appi.ajp.2015.15020266. Epub 2015 Aug 28. PMID: 26315982.

Danese, A., & Tan, M. (2014). Childhood maltreatment and obesity: Systematic review and meta-analysis. Molecular Psychiatry, 19, 544–554.

Dhaliwal, K. K., Orsso, C. E., Richard, C., Haqq, A. M., & Zwaigenbaum, L. (2019). Risk factors for unhealthy weight gain and obesity among children with autism spectrum disorder. International Journal of Molecular Science, 20(13), 3285. doi: 10.3390/ijms20133285. PMID: 31277383; PMCID: PMC6650879.

Diao, H., Wang, H., Yang, L., & Li, T. (2020). The impacts of multiple obesity-related interventions on quality of life in children and adolescents: A randomized controlled trial. Health and Quality of Life Outcomes, 18(1), 213. doi: 10.1186/s12955-020-01459-0. PMID: 32631401; PMCID: PMC7336614.

Gillison, F. B., Lorenc, A. B., Sleddens, E. F. C., Williams, S. L., & Atkinson, L. (2016). Can it be harmful for parents to talk to their child about their weight? A meta-analysis. Preventive Medicine, 93, 135–146. doi: 10.1016/j.ypmed.2016.10.010.

Haines, J., Neumark-Sztainer, D., Hannan, P., & Robinson-O’Brien, R. (2008). Child versus parent report of parental influences on children’s weight-related attitudes and behaviors. Journal of Pediatric Psychology, 33(7), 783–788.

Harriger, J. A. & Thompson, J. K. (2012). Psychological consequences of obesity: Weight bias and body image in overweight and obese youth. International Review of Psychiatry, 24(3), 247–253. doi: 10.3109/09540261.2012.678817.

Hart, L. M., Cornell, C., Damiano, S. R., & Paxton, S. J. (2015). Parents and prevention: A systematic review of interventions involving parents that aim to prevent body dissatisfaction or eating disorders. International Journal of Eating Disorders, 48(2), 157–169.

Heider, N., Spruyt, A., & De Houwer, J. (2018). Body dissatisfaction revisited: On the importance of implicit beliefs about actual and ideal body image. Psychologica Belgica, 58(1), 158–173. doi: 10.5334/pb.362.

Hosogi, M., Okada, A., Fujii, C., Noguchi, K., & Watanabe, K. (2012). Importance and usefulness of evaluating self-esteem in children. BioPsychoSocial Medicine, 6(9). doi: 10.1186/1751-0759-6-9.

Hinz, A. (2017).  Improving body satisfaction in preadolescent girls and boys: Short-term effects of a school-based program. Electronic Journal of Research in Educational Psychology, 15(2), 241–258.

Kahathuduwa, C. N., West, B. D., Blume, J., Dharavath, N., Moustaid-Moussa, N., & Mastergeorge, A. (2019). The risk of overweight and obesity in children with autism spectrum disorders: A systematic review and meta-analysis. Obesity Reviews, 20(12), 1667–1679. doi: 10.1111/obr.12933. Epub 2019 Oct 8. PMID: 31595678.

Lindberg, L., Hagman, E., Danielsson, P., Marcus, C., & Persson, M. (2020). Anxiety and depression in children and adolescents with obesity: A nationwide study in Sweden. BMC Medicine, 18(30). doi: 10.1186/s12916-020-1498-z.

McClelland, J., Robinson, L., Potterton, R., Mountford, V., & Schmidt, U. (2020). Symptom trajectories into eating disorders: A systematic review of longitudinal, nonclinical studies in children/adolescents. European Psychiatry, 63(1), e60, 1–11. doi: 10.1192/j.eurpsy.2020.55.

Mihrshahi, S., Gow, M. L., & Baur, L. A. (2018). Contemporary approaches to the prevention and management of paediatric obesity: An Australian focus. Medical Journal of Australia, 209(6), 267–274.

Mikhailovich, K. & Morrison, P. (2007). Discussing childhood overweight and obesity with parents: A health communication dilemma. Journal of Child Health Care, 11(4), 311–322. doi: 10.1177/1367493507082757. PMID: 18039733.

Moradi, M., Mozaffari, H., Askari, M., & Azadbakht, L. (2020). Association between overweight/obesity with depression, anxiety, low self-esteem, and body dissatisfaction in children and adolescents: A systematic review and meta-analysis of observational studies. Critical Reviews in Food Science and Nutrition, 62(2), 555-570. doi: 10.1080/10408398.2020.1823813.

Murray, M., Pearson, J. L., Dordevic, A. L., & Bonham, M. P. (2019). The impact of multicomponent weight management interventions on quality of life in adolescents affected by overweight or obesity: A meta‐analysis of randomized controlled trials. Obesity Reviews, 20(2), 278–289.

National Eating Disorders Collaboration. (2011). Evaluating the risk of harm of weight-related public messages.

O’Connor, M., Warren, D., & Daraganova, G. (2017). Chapter 11: Eating problems in mid‑adolescence. LSAC Annual Statistical Report. Melbourne: Australian Institute of Family Studies.

Office of Disease Prevention and Health Promotion. (n.d.). Health-related quality of life & well-being.

Pizzi, M. A., & Vroman, K. (2013) Childhood obesity: Effects on children’s participation, mental health, and psychosocial development. Occupational Therapy in Health Care, 27(2), 99–112. doi: 10.3109/07380577.2013.784839.

Pont, S. J., Puhl, R., Cook, S. R., & Slusser, W. (2017) Stigma experienced by children and adolescents with obesity. Pediatrics. 140(6), e20173034. Doi: 10.1542/peds.2017-3034.

Provvidenza, C., Hartman, L. R., Cosgrove, S., Hamilton, J., Crossman, S., Lyons, J., … McPherson, A. C. (2017). Fostering positive weight-related conversations: Evidence and real-life learnings from the heart of care. A Knowledge Translation Casebook for healthcare professionals. Toronto, ON: Holland Bloorview Kids Rehabilitation Hospital.

Puhl, R. & Suh, Y. (2015). Stigma and eating and weight disorders. Current Psychiatry Reports, 17(10). doi: 10.1007/s11920-015-0552-6.

Pulgarón, E. R. (2013). Childhood obesity: A review of increased risk for physical and psychological comorbidities. Clinical Therapeutics, 35(1), A18–32. doi: 10.1016/j.clinthera.2012.12.014. PMID: 23328273; PMCID: PMC3645868.

Rankin, J., Matthews, L., Cobley, S., Han, A., Sanders, R., Wiltshire, H. D., & Baker, J. S. (2016). Psychological consequences of childhood obesity: Psychiatric comorbidity and prevention. Adolescent Health, Medicine & Therapeutics, 14(7), 125–146. doi: 10.2147/AHMT.S101631.

Robinson, E., Daly, M., & Sutin, A. (2020). Association of parental identification of child overweight and obesity and mental health problems during childhood. International Journal of Obesity, 44, 1928–1935.

Robinson, E., & Sutin, A. R. (2017). Parents’ perceptions of their children as overweight and children’s weight concerns and weight gain. Psychological Science, 28(3), 320–329. doi: 10.1177%2F0956797616682027.

Russell-Mayhew, S., McVey, G., Bardick, A., & Ireland, A. (2012). Mental health, wellness, and childhood overweight/obesity. Journal of Obesity, 281801. doi: 10.1155/2012/281801.

Sanders, R. H., Han, A., Baker, J. S., & Cobley, S. (2015). Childhood obesity and its physical and psychological co-morbidities: A systematic review of Australian children and adolescents. European Journal of Pediatrics, 174(6), 715–46. doi: 10.1007/s00431-015-2551-3.

Sawyer, M. G., Miller-Lewis, L., Guy, S., Wake, M., Canterford, L., & Carlin, J. B. (2006). Is there a relationship between overweight and obesity and mental health problems in 4- to 5-year-old Australian children? Ambulatory Pediatrics, 6(6), 306–311.

Sikorski, C., Luppa, M., Luck, T., & Riedel-Heller, S. G. (2015). Weight stigma “gets under the skin”—evidence for an adapted psychological mediation framework —a systematic review. Obesity 23, 266–276. doi:10.1002/oby.20952.

Small, L., & Aplasca, A. (2016). Child obesity and mental health: A complex interaction. Child and Adolescent Psychiatric Clinics, 25(2) 269–282. doi: 10.1016/j.chc.2015.11.008.

Smith, J. D., Fu, E., & Kobayashi, M. (2020). Prevention and management of childhood obesity and its psychological and health comorbidities. Annual Review of Clinical Psychology, 16, 351–378.

Sutaria, S., Devakumar, D., Yasuda, S. S., Das, S., & Saxena, S.  (2019). Is obesity associated with depression in children? Systematic review and meta-analysis. Archive of Diseases in Childhood, 104, 64–74.

Schwimmer, J. B., Burwinkle, T. M., & Varni, J. W. (2003). Health-related quality of life of severely obese children and adolescents. JAMA. 289(14), 1813-1819. doi: 10.1001/jama.289.14.1813. PMID: 12684360.

Tatangelo, G., McCabe, M., Mellor, D., & Mealey, A. (2016). A systematic review of body dissatisfaction and sociocultural messages related to the body among preschool children. Body Image, 18, 86–95. doi: 10.1016/j.bodyim.2016.06.003. Epub 2016 Jun 25. PMID: 27352102.

Truu, M. (2022, January 2). The really old, racist and non-medical origins of the BMI. ABC News.

Walker, L., & Hill, A. J. (2009). Obesity: The role of child mental health services. Child and Adolescent Mental Health, 14(3), 114–120.

Weihrauch-Blüher, S., & Wiegand, S. (2018). Risk factors and implications of childhood obesity. Current Obesity Reports, 7(4), 254–259. doi: 10.1007/s13679-018-0320-0.

Zheng, Z., Zhang, L., Li, S., Zhao, F., Wang, Y., Huang, L., … Mu, D.  (2017). Association among obesity, overweight and autism spectrum disorder: A systematic review and meta-analysis. Scientific Reports, 7, 11697. doi: 10.1038/s41598-017-12003-4.