Childhood Risk Factors for Preoccupation with Thinness: What Your Father Thinks Counts

Stanford researchers recently identified several risk factors for developing a preoccupation with thinness as well as disordered eating, which can begin in childhood and emerge during adolescence and young adulthood. One risk pathway involved parents’ attitudes about their daughter’s body size and weight.

W. Stewart Agras, MD and co-workers at Stanford University designed a study of body image that started literally at birth, when they recruited 216 newborns and their parents at several hospitals in the San Francisco Bay area (J Am Acad Child Adolesc Psychiatry 2007; 46:171). After screening more than 1,000 families, 134 infants and their parents entered the study; 22 were minorities (13 Asians, 6 Hispanics, 2 blacks, and 1 American Indian). The children were followed from birth to 11 years of age.

The study recorded infant feeding behaviors including sucking, length of breast and bottle feeding and difficulty weaning, then evaluated eating behaviors as the infant grew older, such as tantrums over food, over-interest in food, “picky eating,” hiding food, and binge eating and vomiting (parents’ questionnaire). During middle and late childhood, the researchers asked about instances of weight teasing, emotional eating, and the child’s weight and dieting concerns. Activity levels were measured with an accelerometer, which the children wore for 24 hours when they were 3 and 5 years of age, and hours of watching television were recorded by parents on a questionnaire.

Parents were studied, too

The parents themselves were interviewed by a psychiatrist at the beginning of the study to document any eating disorder symptoms and/or any histories of diagnoses of eating disorders. Beginning when the child was 2 years of age, parents filled out questionnaires each year about their concerns about their child’s weight, any disagreements between parents about weight food and feeding, and the use of food limits, for example. Both parents filled out the Eating Disorders Inventory, and the Parental Authority Questionnaire was used to measure parenting style. Later in the study, other questionnaires assessed controlling the child’s weight, commenting on the child’s eating habits, or restricting the child’s eating. Parents’ concern about their own weight was recorded. (See also “Fathers’ Body Images,” on the next page.)

After 11 years, 134 (62%) of the participants were still available for assessment.

Results: Two pathways led to over concern about body size and image

Two major moderators emerged, outlining two different pathways to body dissatisfaction and preoccupation with having a thin body. The first group at greater-than-normal risk of body image disorders had fathers who had a high degree of dissatisfaction about their own bodies. The largest group at risk were females who had fathers who were concerned about their child’s weight and who intervened in some way to regulate the child’s eating and weight. Other risk factors included being teased about their weight by their friends and peers. Hours of watching television emerged as another risk factor (media influences on weight and shape). Independent risk factors included higher scores on drive for thinness and body dissatisfaction for fathers and a higher child activity level at age 5. Picky eating was negatively correlated with thin body preoccupation.

Children with higher BMIs were also at risk

A second group at risk, smaller than the first, was characterized by low parental dissatisfaction and a child with a body mass index (BMI) higher than the 85th percentile at 5 years of age. This subgroup included only 13% of the children in the study. Other independent risk factors were low activity level in early childhood and high eating speed in later childhood, and early parental control of their child’s eating through discouraging comments about food. By late childhood, the independent risk factors, including rapid eating and teasing by parents and peers about weight and shape, predicted over-concern with a thin body shape.

More concern about girls’ shapes and weight

Actions taken by parents to control their child’s weight and shape appear to be focused specifically on their daughters, according to the authors. The higher prevalence of bulimic symptoms in girls may be partly due to the girls’ concerns and interventions to change their weight as a result of their parents’ attitudes and actions. Although media images ordinarily receive a lot of attention as a possible cause of disordered eating, in the authors’ study, the parental effects were far more powerful than any effect from media. However, vulnerable girls, already concerned about their weight and shape, had increased concerns when exposed to media in one study (Stice et al, 2001).

Early intervention is warranted

Dr. Agras and his colleagues note that very early intervention may be helpful for preventing the development of an unhealthy body image because concerns about weight and shape emerge as early as the third grade. Early intervention may be more helpful for changing harmful behaviors than waiting until adolescence, when such behaviors can be more difficult to change. In addition, the results of this study showed that fathers are an important factor in the development of their daughter’s views about their weight and shape (see box on the next page). Thus, both parents should be assessed because the father’s role in the development of a child’s eating disorder is easily overlooked.