Rising Star —

Trigger Warning: Clinical discussion of eating disorders.

Yesterday, I shared the transcript of an interview I had with Dr. Rick Kilmer, Clinical Director of the Atlanta Center for Eating Disorders. Dr. Kilmer warned of the risks that Strong4Life poses to those who are both suffering from eating disorders, or who are at risk for eating disorders.

Adolescent girls are most at risk for developing an eating disorders at an early age, and on the Eating Disorders Help Guide created by CRC Health Group, the authors explain that a pressure to be thin and the association between weight loss and self-worth are contributing factors to this epidemic.

Feeling pressure to be thin increases the likelihood of binge eating and bulimic symptoms… once an eating disorder takes hold, the individual is likely to report low self esteem and an overwhelming need for control. Weight loss and thinness define their sense of self worth.

In addition to our fight against the stigma of Strong4Life’s Phase 1 campaign, we are also fighting the cultural confusion that equates health with thinness. In my interview with Dr. Stephanie Walsh, she repeatedly emphasizes that its Health4Life clinic does not promote weight loss. But on its Health4Life page, they describe the program as follows:

Patient successes from the Health4Life Program include:

• Healthy weight loss and weight management
• Increase in daily physical activity over a sustained period of time
• Consistently improved nutritional intake
• Reduction of incidence of associated co-morbidities such as high blood pressure, high cholesterol and diabetes
• Improved quality of life and self-image

It’s difficult to claim that your clinic is not promoting weight loss when the first item on your list of “patient successes” is “Healthy weight loss and weight management.”

In any case, it may be instructive to learn more about the kids involved in the Strong4Life campaign, starting with Chloe McSwain, aka Maritza.

As you may recall, Chloe does not actually have hypertension and she isn’t the sad, sullen fatty they portray her as. In fact, she’s a talented, young lady with high self-esteem.

On January 20, Chloe took to CBS News to with her mother, Tiffany McSwain, to defend Strong4Life. During the interview, we learn some interesting facts about Chloe. For instance, she has not been “fat” her whole life. “I started picking up weight, lots of weight, when I was about 9 or 10,” she said.

Now, the interview doesn’t go into the cause of her weight gain, but they do say that Tiffany had “struggled with her weight since she was Chloe’s age.”

This is purely inference, but if both mother and daughter began to have “weight issues” around age 9 or 10, do you think this is because around age 9, they both suddenly became gluttonous sloths who shed their self-control in favor of hedonistic delights? Or is there a more rational explanation.

Well, for one thing, the five stages of puberty for girls takes place between the ages of 8 and 13 for girls, and with it comes an anticipated increase in height and weight. According to Dr. Holly Ginsberg, a pediatrician with the Palo Alto Medical Foundation, this “energy preservation” is a natural response to sexual development:

After breasts have started to change, girls will start to notice their hips getting wider, and weight gain in their buttocks, thighs, and abdomen. This is a normal and necessary process the body undergoes to prepare for a potential pregnancy some day. Many girls and their families ask about dieting and weight loss around this time. Children should not go on a diet unless they are being closely monitored by a doctor and/or nutritionist, and are clinically overweight or obese. Instead, the entire family should focus on eating a variety of healthy foods and being active.

Being a guy, I never went through this, so I certainly can’t speak from experience. But if you’re a young, ambitious girl with your eye on the stage, as Chloe does, then I would imagine that even minor changes in body weight, shape or size would be alarming.

And if the response to pubescent weight gain is to prescribe weight loss, then considering the strong correlation between dieting and long-term weight gain, the prescription may be counter-productive. Encouraging, and enabling, ALL kids to eat healthy and get exercise is an important societal goal, but suggesting weight loss is a reasonable response to pubescent weight gain shows just how tricky this balancing act can be.

After all, the designations of “overweight” and “obesity” are arbitrarily set at specific cut-off points. So, if Chloe went from being in the 84th percentile (“healthy”) to the 86th percentile (“overweight”) due to pubescent weight gain, then does she need to lose weight to be healthy in reality?

As I pointed out in this post, a better indicator of “weight problems” is a child’s growth trajectory. If Chloe and her mother were born in the 90th percentile and grew in the 90th percentile throughout their childhoods, then there’s nothing unhealthy about their weight.

Today, I found a similar recommendation in this article from KidsHealth, a site run by Nemours, one of the largest nonprofit organizations devoted to children’s health:

What’s the Ideal Percentile for My Child?

There is no one ideal number. Healthy children come in all shapes and sizes, and a baby who is in the 5th percentile can be just as healthy as a baby who is in the 95th percentile.

Ideally, each child will follow along the same growth pattern over time, growing in height and gaining weight at the same rate, with the height and weight in proportion to one another. This means that usually a child stays on a certain percentile line on the growth curve. So if our 4-year-old boy on the 10th percentile line has always been on that line, he is continuing to grow along his pattern, which is a good sign.

A doctor should monitor the child’s growth over time and look for unusual or unexplained patterns. Now, I’m no pediatrician, but it would seem that if weight gain is a normal side effect of puberty, then when the child’s growth trajectory spikes around age nine, then this would be an explained pattern. It would seem like the doctor’s job would then be to make sure the child is continuing to eat a healthy diet and get exercise, but barring some extreme deviance from the growth rate (the kind discussed in Ellyn Satter’s books), then weight loss shouldn’t even be a part of the equation.

But when you have a weight-based culture of health, it doesn’t matter what a rational approach to childhood obesity says because when the McSwains leave the doctors office, they are still mentally associating weight with health.

In that same CBS interview, McSwain’s feelings of self-worth distinguish her from her peers, “I feel real good about myself, I have lots of self-confidence.” But her decision to be one of the Strong4Life faces is based on an altruistic desire to help other kids get healthy (aka thinner). “It’s really supposed to help them so that they can lose weight and can get healthier.”

Based on the risk factors for EDs that I listed above, Chloe does not seem (on the surface) to suffer from the kind of low sense of self-worth that her preoccupation with weight might otherwise lead to unhealthy behaviors. Elsewhere in the same interview, she exhibits yet another example of her self-confidence and confusion when she says, “I’m very pretty and I needed to start getting healthier and losing weight.”

Although Chloe may have self-confidence in abundance, she may be a rarity. The vast majority of fat kids do not possess her levels of self-esteem.

According to a 2000 study in the Journal of Pediatrics, although obese and non-obese kids have similar levels of self-worth at ages 9 and 10, by the time they reach ages 13 and 14, there is a significant difference:

Overall, 69% of obese white females showed decreased levels of global self-esteem over the 4-year period compared with 43% of nonobese white females. Similarly, 69% of obese Hispanic females showed decreased levels of global self-esteem compared with 43% of nonobese Hispanic females. Changes in global self-esteem among obese white females were similar in upper and lower income families.

What happens between the ages of 9 and 13, or 10 and 14, that causes obese white and Hispanic females to to suddenly feel sadder, lonelier and more nervous than they were just four years prior?

If nearly 3/4 of teenage girls have feelings of low self-worth, then how many do you think, like Chloe, believe that weight loss is the only thing standing between them and health, them and acceptance, them and happiness?

And how does this toxic combination of low self-worth and an increased emphasis on thinness contribute to eating disorders? These are vital questions that we should all be asking, and especially Strong4Life, which is pushing Chloe, an outlier, as representative of fat kids.

An interesting side note that Wendy Brown found: Chloe has an impressive entertainment résumé for an 11-year-old. In fact, she’s performed a solo at Carnegie Hall… no wonder she has so much self-esteem!

But the pertinent page is the detailed description they provide of Chloe.

Baylor College of Medicine has a BMI calculator for children (OH JOY!) that charts your child’s weight status.

According to the BCM calculator, Chloe Swain’s percentile is 94.5, which, according to this chart, makes her “at risk for being obese.” Wait, what happened to just “overweight”?

Technically, Chloe is not obese, but if she were to gain two pounds, she would be obese. Such is the arbitrary nature of BMI cutoff points, and the reason why health professionals recommend monitoring growth trajectories and not a single BMI score.

Oddly enough, the BCM calculator includes the following Q&A:

Should I be concerned if my daughter is in the 75th percentile on the graph?

Not if that is where she has tended to be on the graph in the past (see tracking your child’s weight below). Being in the 75th percentile means that after adjusting for differences in height your daughter is heavier than 75 percent of girls her age ( and lighter than 25 percent), which, according to the CDC guidelines above, puts her at a healthy weight-for-age.

Hmmm… I’m starting to notice a pattern here.

When we focus on weight categories, rather than growth patterns, we run the risk of oversimplifying the issues to the detriment of public health policies. Rather than discussing the progression of Chloe’s growth, Chloe has internalized the message that what really matters is that during puberty she put on weight, a totally natural response to sexual development.

As such, she now believes that she is unhealthy and that in order to regain her health, she must lose the weight she gained during puberty.

What Stephanie Walsh says that this point is irrelevant. What she intends for children to understand about the importance of eating healthy foods and exercising is irrelevant. What resources and educational resources Strong4Life puts out there is irrelevant.

When Strong4Life’s child actors, who are receiving treatment at Children’s Healthcare of Atlanta as part of her compensation, equate losing weight with health and pubescent weight gain with poor health, then we begin to see the unintended consequences of a weight-based health culture. Just how much damage this will do, just how many eating disorders this will spawn, will only come to light decades from now.