The authors of the 2016 American Academy of Pediatrics Clinical Report “Preventing Obesity and Eating Disorders in Adolescents” brought prominence to the evidence that encouraging adolescents to diet may be harmful, increasing adolescents’ risk for both obesity and disordered eating.1 In this issue of Pediatrics, Berge et al2 extend this body of research by examining whether parents’ encouragement of their adolescents to diet may be associated with long-term outcomes. In the results of this 15-year cohort study, it is suggested not only that adolescents whose parents encouraged them to diet continue to be at increased risk for obesity and disordered eating as adults but also that now as parents, these adults are more likely to create home environments for their children that emphasize weight and promote dieting.

How is a clinician to incorporate these findings into practice? The pediatric provider regularly witnesses parents parenting in ways that replicate the parent’s own childhood experiences, for better or worse. The pediatric provider also regularly struggles with how to help parents recognize that some parenting practices that they experienced as children may not be the best strategies to carry forward with their own children. Why is this intergenerational transmission of parenting so difficult to break, and why may it be especially difficult to change how parents parent with regard to eating and weight?

A useful framework for understanding why parents transmit potentially painful parenting practices was described in the now-classic article by Fraiberg et al3 more than 40 years ago: “In every nursery there are ghosts. They are the visitors from the unremembered past of the parents; the uninvited guests. . . .While no one has issued an invitation, the ghosts take up residence and conduct the rehearsal of the family tragedy from a tattered script. The parent, it seems, is condemned to repeat the tragedy of his childhood. . .in terrible and exacting detail.”

Parents remember how they were parented, but they less easily remember how it felt to be parented. In other words, parents remember being encouraged to diet and thus are apt to encourage their own children to diet. But, particularly in the moment of parenting, it is difficult for parents to remember what it felt like to be told to diet. Remembering negative feelings experienced during childhood, especially when those negative feelings were generated by one’s parent, can be painful. Until parents are able to identify those negative emotions and their origins, the parenting practices that evoked them are likely to be repeated in the next generation. In the context of the busy clinic, the pediatric provider might consider asking parents who encourage their children to diet to reflect on whether being encouraged to diet as a child elicited positive or negative feelings and behaviors.

Pediatric providers may also ask parents to reflect on their motivation for encouraging their children to diet. In the case of the struggle with obesity, in our obesogenic and stigmatizing environment, parents are often presented with a quandary. Parents may recognize that encouraging their child to diet runs the risk of being hurtful, but they are so strongly driven to protect their children from the consequences of obesity that the potential harms of encouraging dieting are outweighed.4 These feelings of protection may be particularly fierce among parents with obesity who now see themselves and their own struggles with eating and weight in their children.

Given the accumulating evidence in which it is suggested that parental encouragement of children to diet has unintended consequences, it is essential that we provide parents alternative parenting approaches that speak to their deep motivation to help their children. We also need to recognize that there is not a “one size fits all” approach to promoting children’s positive relationships with eating and weight. Driven by their genetics, children have discernable appetitive traits. For example, some are highly responsive to food cues, whereas others have a strong tendency to eat in response to negative emotions.5 Children with traits such as these may be the most likely to elicit encouragement to diet by their parents because their parents accurately recognize that these children have difficulty self-regulating eating and need greater external structure and support to moderate their intake. Parents of these children in particular need clear and specific guidance regarding how to replace the prevailing dieting discourse with a more effective parenting approach, one that will ultimately be passed on to future generations.

Breaking the transmission of encouragement to diet between generations requires empathy for parents and children alike. It requires an acknowledgment by pediatric providers that obesity has a strong biological component that is transmitted across generations and is poorly understood. It also requires an understanding of the ghosts at the table and how to help parents stop inviting them to dinner.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2017-2955.

1
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Schneider
M
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C
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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.