It’s Not Just About the French Fry

Abstract

The purpose of this article is to explore idiom of distress and its application to overweight and obese adolescent boys. This case study suggests that avoidance, as an idiom of distress, offers self-protection from suffering among this population. Fieldwork included 55 face-to-face contact hours, 25 virtual contact hours (i.e., text messaging, e-mails, phone calls), and 16 person-centered interviews. The daily suffering experienced by this group of boys, and their collective enactment of avoidance as a self-protective strategy, offer an understanding of their lives beyond their obese bodies. Avoidance behaviors, however, can result in negative social consequences such as isolation. Recognizing avoidance as an idiom of distress permits parents, teachers, health professionals, and researchers to interact with overweight and obese adolescent boys in a profoundly different way. Attending to the personhood of these vulnerable boys was an important finding of this qualitative study.

Introduction

Adolescent boys face particular health risks and have specific health, social, and developmental needs (World Health Organization, 2000). Health promotion, prevention, and healthy social development are important to their overall health and well-being (World Health Organization, 2000). Understanding the needs of overweight and obese adolescent boys served as an impetus for this study.

Using a qualitative case study method, the day-to-day lives of overweight and obese adolescent boys were explored. Important considerations when engaging this vulnerable population in nonclinical qualitative research are described. The authors present a synthesis of the literature on both the overweight adolescent body and the overweight boy. Finally, the concept of idiom of distress is introduced. Although avoidance behavior among individual adolescents in general is noted in the literature, our findings reveal avoidance as a collective response to suffering among overweight and obese adolescent boys.

Background

Idioms of Distress

Idioms of distress are social, cultural, and interpersonal ways (i.e., symbols, behaviors, language, or meanings) of expressing, explaining, and coping with distress and suffering (Hollan, 2004; Nichter, 1981, 2010). Idioms of distress manifest in the presence of stressors such as vulnerability, powerlessness, and social marginalization (Nichter, 2010). Applying an idiom of distress framework to those living with disease or experiencing illness can foster further understanding of their lives (Mendenhall, Seligman, Fernandez, & Jacobs, 2010).

In a chapter titled “The Social and Psychological World of the Obese Child,” Buckmaster and Brownell (1988) cite numerous articles dating back to the late 1960s recognizing the peer exclusion, teasing, and ridicule often experienced by overweight children. The distress experienced by overweight children and adolescents has been historically and contemporarily documented by researchers (Berg, Simonsson, & Ringqvist, 2005; Brownell, 1982; Buckmaster & Brownell, 1988; D. Y. Daniels, 2008; Jalongo, 1999; Mellin, Neumark-Sztainer, Story, Ireland, & Resnick, 2002; Pearce, Boergers, & Prinstein, 2002; Puhl & Brownell, 2001; Puhl & Latner, 2007; Staffieri, 1967; Strauss & Pollack, 2003; Stunkard, 1976; Wills, Backett-Milburn, Gregory, & Lawton, 2006). Missing from the literature is a theoretical perspective accounting for a collective response to distress and suffering among overweight and obese adolescent boys. Idioms of distress frame behavior beyond the individual; they represent a collective, systemic, sociocultural phenomenon.

The Overweight and Obese Adolescent Body

The prevalence of overweight and obesity continues to be a major health threat, especially among vulnerable populations such as children and adolescents (Belanger-Ducharme & Tremblay, 2005; Ogden & Carroll, 2010; Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). Data from the National Health and Nutrition Examination Survey indicate that an estimated 16.9% of American children and adolescents aged 2 to 19 years are obese (Ogden & Carroll, 2010). Potential long-term health risks and consequences of childhood and adolescent obesity include the following: hypertension, diabetes, asthma, skeletal abnormalities, sleep apnea, and adult morbidity and mortality (S. R. Daniels, 2006; Maffeis & Tato, 2001; Must & Strauss, 1999; Reilly et al., 2003; Riley, 2005; Serdula et al., 1993).

Behaviors that have the potential to influence overweight and obesity in adolescents are strongly influenced by their environments. Environments include the home (Crossman, Sullivan, & Benin, 2006; Lindsay, Sussner, Kim, & Gortmaker, 2006; Strauss & Knight, 1999; Vaughn & Waldrop, 2007), a community’s built environment (Roemmich, Epstein, Raja, & Yin, 2007; Sallis & Glanz, 2006), and school (Peterson & Fox, 2007; Simon et al., 2006; Story, Kaphingst, & French, 2006).

Specifically, overweight and obese adolescent boys have been identified as a high-risk group warranting early and vigorous intervention (Berg et al., 2005). Prevention and educative strategies are needed to address their current and future health issues (Steen, Wadden, Foster, & Andersen, 1996).

The Overweight and Obese Adolescent Boy

Suffering among overweight adolescents in general includes victimization, bullying, rejection, and social isolation (Buckmaster & Brownell, 1988; D. Y. Daniels, 2008; Jalongo, 1999; Murtagh, Dixey, & Rudolf, 2006; Pearce et al., 2002; Puhl & Brownell, 2001; Puhl & Latner, 2007; Strauss & Pollack, 2003; Thomas & Irwin, 2009; Wills et al., 2006). As a result of social marginalization (Strauss & Pollack, 2003) and peer victimization (Pearce et al., 2002), overweight adolescents disengage and steer clear of participation in sports and physical activities (Amiri et al., 2011; Murtagh et al., 2006; Power, Bindler, Goetz, & Daratha, 2010). Social exclusion and avoidance as a self-protective coping strategy (Thomas & Irwin, 2009) create barriers to a healthy lifestyle (Amiri et al., 2011; Strauss & Pollack, 2003) and a healthy body weight (Murtagh et al., 2006; Thomas & Irwin, 2009).

The day-to-day lives of overweight and obese adolescent boys are replete with suffering. Overweight and obese adolescent boys are subject to being overtly bullied and victimized by their peers, that is, name calling, teased, punched, hit, or kicked (Buckmaster & Brownell, 1988; Murtagh et al., 2006; Pearce et al., 2002). Overweight boys are less likely to be nominated as close friends by their peers (Staffieri, 1967), are less satisfied with their looks, and have fewer friends (Berg et al., 2005). Overweight boys tend to view their own weight as an impediment to social activities, which negatively influences their self-esteem (Thomas & Irwin, 2009).

As will be revealed in this case study, there is a need to move overweight and obese adolescent boys from their marginal social positions to connection and relationship. For overweight and obese adolescent boys, avoidance, as an idiom of distress, acts as a self-protective strategy. Paradoxically, this can lead to further disconnection, self- and social-isolation, as well as limited relationships in the lives of overweight and obese boys.

Case Study

Overweight and obese adolescent boys were invited to participate in a study titled Through Their Voices: Experiences of Overweight and Obese Adolescent Boys. The sampling criteria were fourfold: boys, aged 14 to 20 years, assessed by parents or professionals as overweight or obese, and not involved in an obesity treatment program. Three of the boys were “nominated” by physicians and other health-related care providers who were cognizant of the boys’ obesity, for example, body mass index. The other boy was nominated by his parents. Of interest, parents most often underestimate the weight of their overweight and obese children, especially with their sons (Jordan et al., 2009). The researchers did not weigh the boys but relied on the nominators to refer overweight and obese participants. The boys were not weighed as the researchers did not want them to be judged yet again; moreover, weighing the boys would have undermined trust with the researchers. Thus, the numerical extent of their obesity remained unknown. The research study received ethical approval from the Human Subjects Research Committee at the University of Lethbridge. Three participants signed assent forms; their parents signed consent forms. One participant signed a consent form.

Recruitment was held over a 10-month period. The recruitment strategies for this study were based on the guidance of an Advisory Committee (clinical, nonclinical, and research experts) and existing recruitment literature concerning vulnerable populations, overweight adolescents in general, and nonclinical settings (McCormick et al., 1999; Thomas & Irwin, 2009; UyBico, Pavel, & Gross, 2007). Disappointingly, these recruitment efforts failed to accrue the proposed participant sample (N = 20). Four participants between the ages of 14 and 20 years were eventually recruited. Sandelowski (1995) observes that sample size refers to not only the number of persons but also to the number of interviews, events, and observations. The small sample size within this study is in keeping with the case study method design (Stake, 2005; Yin, 2009) and involved deep exploration of a phenomenon through multiple data collection methods.

Participants met biweekly for a variety of group activities (i.e., movies, video games, dinners). Halo Wars™, an Xbox video game, was the main stay activity used to develop trust and rapport between the boys and with the lead researcher (ZM). Individual interviews were conducted at community locations (i.e., coffee shops, community college). The one-on-one interviews explored the daily lives of the participants. Trust surrounding the interview process did not happen quickly but required several months and many hours at both the group and one-on-one levels of engagement. Generally, adolescent boys are hesitant to share their feelings and concerns on sensitive topics such as body image within a group setting (Hargreaves & Tiggemann, 2006); therefore, extensive measures were taken in this case study to establish trust and rapport.

Fieldwork observations (Patton, 2002), group activities, and 16 person-centered interviews (Hollan, 2005; Levy & Hollan, 1998) were held over a 5-month period and included 55 face-to-face contact hours, as well as 25 hours of virtual contact (i.e., text messages, e-mails, phone calls). Importantly, and in contrast to existing research, this study and the data collection methods therein front staged the boys and their lives, while back staging their overweight and obese bodies.

Participants are identified through acronyms, based on each of their interests, that is, EO (Edmonton Oilers), NY (New York), MB (Motor Bike), and GP (Guitar Player). Although this approach served to protect participant anonymity, it also offered each boy an identity within the findings. Throughout the case study, the participants are referred to by their acronyms.

Findings

The findings from this study are based on 10 months of recruitment efforts and 5 months of data collection. The relationship between the participants and the lead researcher (ZM) was well established, but after 5 months of interviews and fieldwork the boys remained reticent to share their feelings and insights about their lives. The participants often shied away from emotionally imbued accounts of their experiences. Moreover, the way in which the boys formulated their speech (lexicon) defied eloquent and rich textual description. However, person-centered interviews, fieldwork, and participant observations established data triangulation (Lincoln & Guba, 1985). Through participant observations and field notes, insight was gained into the participants’ natural interaction with others and their environments (Patton, 2002; Sandelowski, 1995). Thus, the corpus of the findings offers reasonable evidence of the boys’ suffering and their collective response to it, that is, avoidance as an idiom of distress.

Suffering Experienced by Overweight and Obese Boys: Avoidance as an Idiom of Distress

Bullying within the school environment

During one interview Participant EO was asked what constituted a good day at school, and in a very soft voice he replied, “Not having anyone pick on me.” Puhl and Brownell (2001) identify the challenges, such as peer rejection, that overweight adolescents experience in educational settings. During conversations in the field, all the boys identified that they disliked school (they often said they “hated school”) and were subject to bullying within the school context. As D. Y. Daniels (2008) observes, any deviation from normal body weight can result in bullying. In addition, all the boys regularly discussed their many school absences. For the boys, being ill at home was a better alternative then attending school and being subjected to bullying.

Being judged: Collective avoidance of social situations

Here’s the thing, I walk into a room and. . . . You already can tell that you’ve been judged. Like someone who’s bipolar and who . . . they can hide that pretty well and still live a very normal life and people don’t know . . . like don’t judge a book by its cover right! Because when you start to flip through, I’m a pretty good book. (Participant NY)

The observation by Participant NY captures a very important experience. Overweight and obese adolescents are judged by what others see, and furthermore, Participant NY indicates that weight as an illness or disease cannot be hidden. Thus, these boys are vulnerable in potentially every social situation in which they find themselves. As previously identified, the mainstay of the group activities for this study was Halo Wars™. The game was played in an isolated room booked solely for this group in the basement of the local library. This collective activity choice and location enabled the boys to avoid other potentially uncomfortable social environments or group activities and moreover minimized the risk of being judged in social contexts.

Another indicator suggesting a collective avoidance response by these boys surfaced in the recruitment phrase of this nonanonymous research study. Participants were asked directly why the researchers’ recruitment efforts produced such limited interest from overweight and obese boys in the community. The boys suggested that prospective participants avoided the unknown and thus a potentially unsafe social environment in which they would be judged:

I don’t know, maybe people would be kinda of embarrassed I guess, I don’t know. Like, I don’t know, if people are walking around they’re not going to tell your friends to stop and wait, so you can read this ad for a group [overweight and/or obese boys] for that! (Participant GP)

Cause a lot of people are probably not open about it, kinda thing. (Participant EO)

The boys within this study collectively avoided environments, social interactions, and many activities that were uncomfortable for them as a consequence of cumulative distress several years in the making. Even with their assent to participate, it was observed that the boys’ initial response was to avoid participation in group activities, gatherings, and interviews. Interestingly, and after a period of 5 months, the boys began to participate more fully in group activities and demonstrated more comfort in being interviewed. Furthermore, and through the process of the research study, it became apparent that the boys had established a peer group in which they found trust, safety, and comfort with each other. Near the end of the study, the boys shared comments such as, “This is the most fun I’ve ever had” and “I enjoy hanging out with you guys.”

Marginalized by persons in positions of authority

Our findings also suggest that the marginalization experienced by overweight and obese adolescent boys is not only attributable to peers but also to persons in positions of authority in their lives, including teachers and health care providers. Such findings are confirmed within the literature (Murtagh et al., 2006; Neumark-Sztainer, Story, & Harris, 1999). Although all the participants expressed difficulties at school and with their teachers, two interview excerpts are exemplary in this regard:

She (Teacher) didn’t like me either, she would phone my parents every chance she got. I just got the vibe, she didn’t like me, she . . . she wrote down a lot of stuff that was BS on my report card. . . . Yeah, I actually went to Parent Interviews with my teacher this year and I tried to kind of defend myself, because she was telling my mom a bunch of stuff that was kind of lies. (Participant GP)

I had never been sent to the office in my entire life, up until grade nine, like never been, and I don’t know what it was but there was one teacher that I had, I walked into class and on the second day and he said, “Get out.” I was like, okay . . . you know, and so I was like why, and he’s like, I just don’t want you here, you’re a menace in my class, get out. And I was like, okay I haven’t said anything, but okay. (Participant NY)

During one interview, Participant MB expressed his anger toward a health professional from whom he had sought help for his dietary practices. He responded in a powerful way:

The dieticians issues are done. If I have one fuckin French fry a year, I’m fuckin bad. I went out once in that whole . . . I don’t know it seemed like four months I think. I went out once and I got my ass kicked by her. But yeah, she can sit there and eat a whole bowl of popcorn in front of me. That would . . . that was the thing that pissed me off, you know some dietician, they’d always say, oh you’re eating something wrong . . . I went there, I hate them . . . oh you should be eating vegetables, I get more . . . I get over four cups of vegetables a day. Like I eat what you’re supposed to eat, you’re supposed to get, like you’re supposed to get like eight cups of vegetables a day, and I eat . . . apparently you’re supposed to eat about 16 oz. of meat a day. Do you know how much is 16 oz. of meat a day? (Participant MB)

This strong reaction shared by Participant MB was not surprising. From his perspective, the dietician focused on a sole behavior contributing to his obese body (i.e., enjoying some French fries). In reality, he was clearly aware of healthy eating habits and may have enjoyed French fries as a special treat on occasion. As a result of this interaction, Participant MB eliminated dieticians as a resource within the context of his life. Persons in positions of authority would be wise to recognize that overweight adolescent boys may express avoidance as a preemptive response to being judged. Judging overweight and obese adolescent boys may also lead to further collective avoidance behavior.

Discussion

Researchers are bringing forth the voices of overweight and obese adolescents through qualitative research (Amiri et al., 2011; Murtagh et al., 2006; Power et al., 2010; Thomas & Irwin, 2009). Their voices are speaking loud and clear, indicating that they not only need protection from the physiological effects on their bodies but also need community members to attend to their personhood (i.e., the contexts of their lives and not just their bodies).

The overweight and obese adolescent boys in this study voiced that their personhood (Cassell, 2004) was judged exclusively on their corporality and this precipitated suffering among them. All the boys were subject to bullying from their peers and felt judged from persons in positions of authority (i.e., teachers, health care providers, and others). The distress and suffering experienced by the boys in this study is confirmed elsewhere in the literature (Buckmaster & Brownell, 1988; D. Y. Daniels, 2008; Jalongo, 1999; Murtagh et al., 2006; Puhl & Brownell, 2001; Thomas & Irwin, 2009).

Idioms of distress (Nichter, 1981) provide the opportunity to understand a collective response to the distress and suffering experienced by overweight and obese adolescent boys. Although the literature provides examples of avoidance as an individualistic self-protective coping strategy (Amiri et al., 2011; Murtagh et al., 2006; Power et al., 2010; Strauss & Pollack, 2003; Thomas & Irwin, 2009), our findings suggest that avoidance is an idiom of distress among these boys. This idiom of distress helps us understand how their suffering is revealed in the collective withdrawal into what Cassell (2004) notes as “private worlds.” The marginal social positions occupied by overweight and obese adolescent boys may benefit from connection and relationship. Avoidance precipitates disconnection, self- and social-isolation, and limited relationships. Although avoidance provides protection from distress within their worlds, adolescents rely on peers for their development and maintenance of self-image, self-acceptance, and sense of belonging (Pearce et al., 2002; Strauss & Pollack, 2003). Paradoxically, a protective expression of avoidance may lead to further social isolation.

Future research recommendations include the following: explore idioms of distress among overweight and obese adolescent boys from diverse sociocultural and socioeconomic backgrounds, further validate avoidance as an idiom of distress among overweight and obese adolescent boys through quantitative and mixed method research design, and identify and evaluate strategies to assist these boys to move from disconnection and isolation to connection and community.

Study limitations include the following: the research was conducted in one midsized city; all the boys were from similar sociocultural backgrounds; although the researchers justified not weighing the boys, no metric was used to establish the extent of obesity among the boys; the study excluded overweight and obese adolescent females; and finally the results are based on one single case study, and thus the authors recommend further validation of the findings through additional case studies and mixed method research design.