Journal Mobile Options
Table of Contents
7, No. 1, 2014
Issue release date: February 2014
Section title: Original Article
Open Access Gateway
Obes Facts 2014;7:1-14
(DOI:10.1159/000357601)

Adolescent Overweight, Obesity and Chronic Disease-Related Health Practices: Mediation by Body Image

Farhat T.a · Iannotti R.J.a · Caccavale L.J.b
aPrevention Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, bDepartment of Psychology, Virginia Commonwealth University, Richmond, VA, USA
email Corresponding Author

Abstract

Background/Aims: To examine whether body image mediates the association between overweight/obesity and chronic disease-related health practices (CDRHP), including lack of physical activity (PA), infrequent breakfast consumption (IBC), screen-based media use (SBM), and smoking. Methods: The 2006 Health Behaviors in School-Age Children survey was administered to a nationally representative sample of US students (n = 8,028) in grades 6-10 (mean age = 14.3 years). Outcome variables included self-reported measures of PA, SBM, IBC, and smoking. Body image was assessed with 5 items from the Body Investment Scale (α = 0.87) asking for agreement/disagreement with statements about one's body. Stratifying on gender, an initial regression model estimated the association between overweight/obesity and CDRHP. Mediation models that included body image were then compared to the initial model to determine the role of body image in the relationship between overweight/obesity and CDRHP. Results: Among boys, body image mediated the relationships of overweight/obesity with SBM, and of obesity with IBC. Among girls, it mediated the relationships of obesity with PA, IBC, and smoking, and of overweight with SBM. Conclusion: As the prevalence of overweight/obesity among adolescent boys and girls remains high, efforts to improve their body image could result in less frequent engagement in CDRHP.

© 2013 S. Karger GmbH, Freiburg


  

Key Words


  • Adolescents
  • Obesity
  • Body image
  • Chronic disease-related health practices


 Introduction

Overweight and obesity among US adolescents remain a public health concern with a third of youth aged 12-19 years being overweight or obese [1]. Of particular concern is the co-occurrence of overweight/obesity with health practices that are associated with chronic diseases such as diabetes and cardiovascular diseases [2]. These health practices include smoking [3], sedentary behavior [4], lack of physical activity (PA) [4], and, as recent studies are showing, infrequent breakfast consumption (IBC) [5]. Given that health practices established during adolescence are likely to be sustained into adulthood, understanding processes by which youth obesity is associated with chronic disease-related health practices (CDRHP) could provide benefits that extend well beyond the adolescent years [6.]

 Association of Overweight with Chronic Disease-Related Health Practices


The association of adolescent overweight/obesity with smoking varies by gender and geographic location. Among US adolescents, early adolescent (<15 years) overweight and obese girls were 1.75 and 1.77 times more likely to smoke, respectively, than their normal-weight peers, and mid-adolescent (≥15 years) obese girls were 2.05 times more likely to smoke. No associations were observed for boys in this sample [7]. However, among a nationally representative sample of Danish school children, a mirror pattern was observed, with a positive association between overweight and smoking only observed among boys [8]. The systematic review of the association of overweight with smoking by Potter et al. [9] supports these conflicting gender differences, which may be dependent on weight concerns and smoking stage.

Overweight and obesity have been negatively associated with breakfast consumption and PA, and positively associated with screen-based media use (SBM) across multiple countries [5,10]. In a cross-national study of the association of overweight with lifestyle factors, Haug et al. [5] showed that the odds of breakfast consumption among overweight adolescents ranged from 0.48 (the Netherlands) to 0.79 (Finland), while those of PA ranged from 0.50 (Iceland) to 0.78 (Germany and Greece).

 Association of Body Image with Obesity and Chronic Disease-Related Health Practices


Perceptions of body image may be an essential component of pathways linking adolescent overweight/obesity and CDRHP. Adolescent overweight and obesity have been associated with the development of a negative body image [11]. Negative body image is associated with a multitude of adverse behavioral and health outcomes including impaired mental health (depression, low self-esteem) [12], poorer self-reported health [13], risk behaviors (substance use and abuse) [14,] internalizing and externalizing problem behavior [15], lower engagement in PA [16], increased sedentary behavior [16], and poor dietary choices (unhealthy dieting, poor dietary intake) [17]. In contrast, positive body image has been linked to less weight-related concerns and behaviors as well as to parental and peer attitudes encouraging healthy eating [18].

However, no identified study has examined the possible mediating effect of body image on the associations of overweight/obesity with CDRHP. This is a useful inquiry because the presence of a mediating role for body image may have implications for prevention programs: improving body image among overweight/obese adolescents may lead to greater engagement in PA, less SBM, less smoking, and more frequent breakfast consumption.

Studies examining the association of weight status and body image with CDRHP outcomes are limited by several factors. They either included weight status or body image as predictors, but rarely both variables simultaneously [8,19]. Research suggests, however, that both measures are intimately linked and that failure to account for one may alter the association of the other with the outcome (e.g., confounding) [5,6,13]. Further, studies in adult women are showing that, rather than functioning as an independent covariate, body image may actually be a mediator of the association of overweight/obesity with outcomes such as depression [20] and weight loss [21]. Similar mediating pathways have not been examined for skipping breakfast or smoking, although these behaviors are highly prevalent among overweight/obese youth [6,22,23]. Finally, most of the research examining the role of body image has focused only on girls, and it is not clear the extent to which body image may also be a useful mediator for the association of overweight/obesity with CDRHP among boys.

 Gender Differences in Body Image


Gender differences in body image are observed, with girls reporting worse body image than boys [24]. Pubertal changes during adolescence trigger modifications in physical appearance, weight, and fat distributions. Adjusting to these changes and accepting one's physique is one of the essential developmental tasks of adolescence [25]. However, adolescents, particularly girls, are confronted with messages from the media, peers, and parents highlighting thinness as an ideal body size [26], thus impeding acceptance of their own bodies and fostering negative body image [27]. In contrast, boys are exposed to images of ideal muscular physiques which, when unreachable, may also trigger a negative body image [24].

 Theoretical Framework


Social comparison as well as stress and coping theories provide a useful framework for this study. Social comparison theory posits that individuals compare themselves to others to establish similarities and differences about their own attributes, skills, and social expectations [28]. These evaluative comparisons may generate negative outcomes, particularly when the gap between the individuals' own attributes and those of the comparison object is wide, thus making it difficult for individuals to conform to the ideal attribute. In the case of overweight/obese adolescents, idealized thin body images are often impossible to attain, therefore creating a constant internal state of stress [28].

According to the stress and coping theory, adolescents use a variety of coping strategies to deal with stressors, some of which may actually be maladaptive and exacerbate the stressor instead of eliminating it [29]. This may be particularly true for adolescents dealing with the stress of excess weight or negative body image. Previous research has identified children and adolescents resorting to increased TV viewing time [30], smoking [31], and unhealthy eating patterns [17] to cope with stress, all behaviors that may reinforce overweight/obesity and affect adolescents' future risk for chronic disease. Adolescents who are experiencing the stress of negative body image may resort to such maladaptive coping strategies. Further, adolescents may shy away from some health-enhancing behaviors because of the increased stigma they may face. For example, overweight/obese adolescents experience increased weight criticism during PA, which is associated with reduced sports enjoyment, avoidance of exercise, and lower intensity PA [32]. Reducing exposure to the stressor, in this case, negative body image, may therefore lead to lower engagement in unhealthy behavior.

 Purpose of the Study


The primary purpose of this study is to determine whether body image mediates the association between overweight/obesity and CDRHP among adolescents.

 

 Material and Methods


 Sample


We conducted the United States 2005/6 Health Behavior in School-Aged Children (HBSC) study, a quadrennial survey of a nationally representative school-based sample. More information on the methods and procedures can be found at www.hbsc.org. A three-stage stratified clustered sampling, with classes as the sampling units, was used to select a sample of American students in grades 6-10 during the 2005/6 academic school year. African-American and Hispanic students were oversampled to provide better population estimates for these minorities.

Self-report questionnaires were administered in the classrooms; the data collection process was designed to assure the anonymity and confidentiality of the students' responses. Ethics approval was obtained from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Institutional Review Board.

Of the students eligible for the study, 87% (9,227) completed the questionnaire. For logistical reasons, half of the 6th graders who completed the questionnaire were not asked the question on body image and were therefore excluded from the analysis, as were respondents who did not identify their gender (n for analysis = 8,028).

 Measures


 Physical Activity

Students were provided with a definition of PA and examples of moderate-to-vigorous PA. It was then assessed with a question asking about the number of days the respondent engaged in at least 60 min of PA over the last week. Response options ranged from 0 to 7 days.

 Screen-Based Media Use

Responses to questions asking how many hours per a) weekday and b) weekend day respondents watched 1) television or 2) played on a computer or game console during their free time were combined into a single continuous measure of sedentary behavior. Response options were none, 0.5 h, 1-7 h or more hours. Mean hours per day of television and computer use were calculated and summed to create an SBM score.

 Breakfast Consumption

Respondents indicated how often they usually had breakfast on weekdays and weekends (response options: 0-5 days for weekdays; 0-2 days for weekends). Answers to both questions were averaged to calculate weekly breakfast consumption.

 Cigarette Smoking

Respondents indicated on how many occasions they had smoked cigarettes in the last 30 days (range: ‘never' to ‘40 times or more'). This measure was dichotomized to reflect any use.

 Body Mass Index Measurement and Obesity Classification

BMI was computed from adolescents' self-reported height and weight, which studies have shown to be adequate estimates for actual height and weight [33]. BMI-for-age percentiles for each gender were derived using the CDC (Centers for Disease Control and Prevention) 2000 growth chart [34]. BMI-for-age weight status categories and the corresponding percentiles, using the CDC 2000 growth chart for US children, were as follows: adolescents were considered underweight if their BMI was <5th percentile; normal weight if their BMI was ≥5th but <85th percentile; overweight if their BMI was ≥85th but <95th percentile; and obese if their BMI was ≥95th percentile. For these analyses, we excluded underweight respondents, who constituted only 4% of the sample.

 Body Image

Body image was assessed as a continuous variable created from the mean of 5 items (α = 0.87) from the body image subscale part of the Body Investment Scale (BIS) [35]. The first subscale of the BIS was constructed to measure body image feelings as well as attitudes and measures several aspects of body image: evaluation, attitudes, and emotions. This scale has been validated and used in other studies [36] to assess body image in adolescents. Questions asked the respondents how much they agreed or disagreed with the following five statements: ‘I am frustrated with my physical appearance', ‘I am satisfied with my appearance', ‘I hate my body', ‘I feel comfortable with my body', and ‘I feel anger toward my body'. The scale ranged from 1 to 5, with higher scores indicating more positive body image.

Measures of PA, SBM, breakfast consumption, and smoking were coded such that higher values indicate more engagement in the behavior.

 Demographic Characteristics

Demographic characteristics included gender, age, race/ethnicity (White/Black/Hispanic/Other), and family affluence scale (FAS). FAS, an indicator of adolescents' socioeconomic status (SES), was constructed from questions about family wealth. The scale was categorized into tertiles and has good content and external validity [37].

 Analysis


We used STATA 9.0 for all analyses to adjust for the cluster-based sampling design of HBSC. Weights (defined as the inverse probability of selection) were applied to provide nationally representative estimates. Descriptive statistics (frequencies, weighted percents, means) were computed for all variables. Bivariate statistics identified the associations between weight status, body image, and health practices (these results are not displayed given that they are very similar to those from the multivariable analysis). Indicators for other health behaviors (e.g. dieting) were not included, as they may act as mediators between weight status and the health practices under investigation. Linear or logistic regression models, stratified by gender, were then fitted to obtain adjusted estimates for the association of weight status to health practices variables. We chose to stratify models by gender given the established evidence of the differential association of weight status to body image [11] and to health practices [3] among boys and girls.

Following the approach of Baron and Kenny [38], we established that body image acts as a mediator if three steps in the regression analysis are verified: Overweight/obesity is significantly associated with body image (step 1). Body image is significantly related to CDRHP in multiple regression models including overweight/obesity and controlling for respondents' race/ethnicity, SES, and age (step 2). Finally, when body image is added to the initial models, a previously significant relationship between overweight/obesity and health practices is no longer significant (complete mediation) or significantly reduced (partial mediation) (step 3). Partial mediation was established by using the Sobel test.

For each model, we also conducted a joint Wald test of the coefficients for overweight and obesity to assess whether they were significantly different from each other. If the Wald test was not significant, we concluded that the association of overweight with CDRHP was not significantly different from that of obesity with CDRHP.

 

 Results


 Sample Description


Approximately 50% of the sample were boys. Most respondents were non-Hispanic Whites and of middle SES. Mean age was 14 years for boys and girls (range: 9.7-17.3 years) (table 1). About 68% of the total sample were of normal weight, 18% were overweight, and 14% were obese. Boys were significantly more likely than girls to report positive body image, PA, SBM, and breakfast consumption. They were also more likely than girls to be overweight/obese.

TAB01
Table 1. Sample characteristics: Prevalence and means

Race/ethnicity and family affluence significantly differed by overweight/obesity for boys and girls (table 1), with more Hispanic and African-American adolescents, and those of middle SES, being obese. About a quarter of the obese girls reported smoking, but smoking did not differ by overweight/obesity among boys. Body image was most positive, PA highest, breakfast consumption most frequent, and SBM lowest for normal-weight boys and girls.

 Steps 1 and 2 of Baron and Kenny's Mediation Analyses for Boys and Girls


Overweight and obesity were negatively associated with body image among boys and girls (tables 2, 3), in accordance with step 1 of Baron and Kenny's mediation analyses, whereby the independent variable is significantly associated with the mediator. Controlling for race/ethnicity, SES, and age, positive body image was associated with more PA and breakfast consumption and with less SBM and smoking among boys and girls (table 4), thereby verifying step 2 of Baron and Kenny's mediation analyses.

TAB02
Table 2. Regressions for the association of body image with the CDRHP

TAB03
Table 3. Regressions for the association weight statusa and body image

TAB04
Table 4. Weight status, body image, and obesity-related health practices: mediation models for boys

 Step 3 of Baron and Kenny's Mediation Analysis for Boys


Table 4 presents the coefficients from the multivariable regression models for boys. The initial models evaluate the association of overweight/obesity with CDRHP, controlling for age, race/ethnicity, and SES. For boys, overweight and obesity were negatively associated with PA and positively associated with SBM, with the associations being stronger for obesity (Wald tests: p < 0.05). Obese boys were also less likely than normal-weight ones to report breakfast consumption. No associations were observed between overweight/obesity and smoking.

When body image was added to the models, the strength of the association between overweight/obesity and PA decreased, as evidenced by significant Sobel t-tests. The associations between overweight/obesity and SBM as well as between obesity and breakfast consumption were no longer significant when body image was taken into account.

 Step 3 of Baron and Kenny's Mediation Analysis for Girls


In the initial models for girls, obesity was negatively associated with PA and breakfast consumption and positively associated with SBM and smoking (table 5). Overweight was positively associated with SBM, but the association was significantly less than the association between obesity and SBM (Wald tests: p < 0.05). Overweight was not associated with PA, breakfast consumption, or smoking.

TAB05
Table 5. Weight status, body image and obesity-related health practices: mediation models for girls

When body image was added to the models, the parameter estimates for the associations between obesity and health practices and between overweight and SBM were reduced. The degree of reduction varied across health practices, but for most outcomes, previously significant associations between weight status (mainly obesity) and health practices became nonsignificant after taking body image into account.

 

 Discussion

These analyses of a nationally representative sample of boys and girls confirm our hypothesis regarding the mediating role of body image across gender and behaviors: For boys, having a negative body image completely accounted for the positive association between overweight/obesity and SBM and between obesity and IBC, and it partially explained the negative association between overweight/obesity and PA. Among girls, having a negative body image completely mediated the association of obesity with PA, breakfast consumption, and smoking, partially mediated that of obesity with SBM, and completely mediated that of overweight with SBM. These findings point to the usefulness of evaluating body image to understand processes influencing the association of overweight/obesity with CDRHP.

As suggested by social comparison theory, adolescents engage in comparative evaluations with external attributes to establish commonalities and differences with their own attributes. For overweight/obese adolescents, comparing their body image to impossibly thin standards publicized by the media and society results in stress that is sometimes addressed through maladaptive coping strategies such as increased SBM [30], smoking [7,] or an inadequate dietary lifestyle (e.g. skipping breakfast) [17], all behaviors that could either result in maintaining overweight/obesity or worsening the negative health consequences of obesity. Furthermore, the desire of overweight/obese adolescents to conform to their peer group may conflict with a potential engagement in health-promoting behaviors, given that such behaviors conflict with processes and values that are central to adolescence (e.g. risk taking, being ‘cool') [39].

Compared to overweight/obese individuals in other developmental stages (such as children and adults), overweight/obese adolescents are more likely to demonstrate maladaptive coping through engagement in risk behavior. Overweight/obese adolescents experience impaired peer relationships, stigmatization, and weight bias. These stressful life events, in combination with the normative challenges of adolescence and the stress of managing an unhealthy weight, may make adolescents more susceptible to engaging in health-risk behaviors. [7]

To our knowledge, this is the first study examining the mediating role of body image in the overweight/obesity-CDRHP association among adolescents, particularly among boys, who have traditionally not been the focus of body image research. However, previous studies have identified the use of maladaptive coping strategies such as poor dietary habits and negative self-talk as a reaction to weight stigma among adults [40]. Negative body image has been firmly established as a potential stressor for adolescents, particularly for those who are overweight or obese. As suggested by the stress and coping theory, experiencing a negative body image is therefore likely to trigger coping strategies aimed at mitigating the emotional and physiologic imbalances caused by a negative body image. Unfortunately, among overweight and obese adolescents, such coping strategies could involve practices such as smoking and increased SBM, which are maladaptive and may worsen obesity or its negative health consequences.

Our findings show that overweight/obesity is negatively associated with PA and breakfast consumption and positively associated with SBM and smoking. These associations varied by gender and degree of overweight: obesity was associated with all CDRHP across gender (except smoking for boys), but the association of overweight with CDRHP was more limited. For boys, it was only associated with PA and SBM, while among girls, it was only associated with SBM. While different studies have established associations of overweight/obesity with PA/SBM [4,10], smoking [7], and skipping breakfast [5], this is the first study to examine the association of varying degrees of overweight with multiple CDRHP, across gender, and in a national sample. These findings suggest that prevention efforts aimed at curtailing the obesity epidemic could also simultaneously address other CDRHP to prevent such risk behaviors from becoming habitual and being sustained in adulthood.

The association between overweight/obesity and CDRHP was stronger for obese compared to overweight adolescents across gender and behavior. The stronger association of obesity with CDRHP could possibly relate to greater experiences with stress and stigma. Previous studies have shown that obesity was associated with more negative outcomes than overweight [7], thereby confirming that greater deviations from appearance ideals were significant factors in the relationship of overweight/obesity with risk behaviors. Indeed, in this study, obesity was more strongly associated with poor body image - a potential source of stress - than overweight. The poorer the body image, the greater the stressful experience, and the stronger the engagement in CDRHP (table 4).

Body image was negatively related to overweight/obesity, SBM, and smoking, and positively related to PA and breakfast consumption, across gender and after controlling for age, race/ethnicity, and family affluence. These findings are in line with previous research showing that overweight/obesity is a strong and consistent risk factor for developing a negative body image in adolescence [11] and that negative body image is associated with CDRHP [14,16,17]. Negative body image has also been associated with a host of health-compromising practices among adults, including less walking/jogging and a worse diet, suggesting that the adverse consequences of a negative body image may be similar across the life course.

These findings should be interpreted in light of the limitations and strengths of this study. One important limitation lies in the cross-sectional nature of the data that makes it difficult to test for the temporal sequence of these events. In this study, we hypothesized that overweight/obesity among adolescents leads to a negative body image, which would, in turn, lead to greater engagement in CDRHP. Although these assumptions are justified and in line with previous research documenting the association of overweight/obesity with body image and that of body image with CDRHP, we cannot completely rule out different causal directions. For example, PA may promote a positive body image which could lead to healthier weight (e.g. through weight maintenance). Our results can therefore be further strengthened by testing these relationships using longitudinal data.

Another limitation relates to our inability to draw a distinction between adolescents with and without obesity-related comorbid conditions (e.g. diabetes). Overweight/obese adolescents with one or more of these conditions may have different body image perceptions than those with no conditions. Furthermore, the addition of comorbid conditions may alter the association of overweight/obesity with CDRHP. Indeed, different findings have emerged regarding the association of chronic conditions with CDRHP such as smoking, with studies showing positive [41] or negative [42] associations. If chronic conditions are indeed associated with an increased risk of smoking and other CDRHP, more research is needed to determine the extent of the association of overweight/other chronic conditions with body image and to determine whether negative body image is still as effective a mediator in the association of overweight/other chronic conditions with CDRHP.

This study relied on subjective measures of height and weight to compute the BMI score, and, although these measures are adequate estimates of actual height and weight [33], objective measurements would provide a stronger argument for these relationships. Finally, although body image was an effective mediator of the relationship of overweight/obesity with CDRHP, the small R2 of the regression models suggests that factors other than body image may play a stronger role in the association of overweight/obesity with CDRHP.

Despite these limitations, our study has several strengths. First, these analyses were based on a representative sample of US adolescents with varying degrees of overweight, which enabled us to examine the mediating effect of a negative body image across different subgroups, rather than only focusing on clinical samples with the most extreme cases of obesity. As our results have shown, the association between overweight/obesity and CDRHP differed by weight status, as did the mediating effect of body image. Other notable strengths include the use of previously tested and validated measures and the simultaneous investigation of the association of overweight/obesity with multiple CDRHP.

These findings also have implications for public health practice. Prevention programs that address PA, sedentary behavior, unhealthy eating (skipping breakfast), and smoking among adolescents should include an assessment of body image along with weight status, as these factors might be contributing to the adolescents' engagement in these CDRHP. As this study showed, perceptions of body image may be an important determinant of engagement in CDRHP. Therefore, altering body image perceptions to be more positive may facilitate behavior modification and less engagement in CDRHP.

Future research should also investigate the applicability of the proposed framework to different subgroups of adolescents. For example, while the prevalence of a negative body image is higher among White girls than African-American girls, we had no a priori reasons for assuming that our framework will not be applicable to both groups. Even though the prevalence of negative body image differs among the two groups, we would expect, based on stress and coping theory, that in either group a negative body image will lead to greater engagement in CDRHP. However, this hypothesis needs to be investigated in future studies.

 

 Conclusions

In conclusion, these findings suggest that a negative body image effectively mediates the association of overweight/obesity with CDRHP, although, as indicated by the overall model fit (small R2), additional mediators need to be investigated. Prevention strategies and programs may benefit from promoting more positive body image perceptions, especially among overweight/obese youth. As the prevalence of overweight/obesity among adolescent boys and girls remains high, efforts to improve their body image could result in greater engagement in PA, more frequent breakfast consumption, and reduction in smoking and SBM, all changes that could reduce the clinical health consequences of overweight/obesity.

 

 Acknowledgements

This research was supported in part by the intramural research program of the NIH, Eunice Kennedy Shriver National Institute of Child Health and Human Development (Contract N01-HD-5-3401), and by the Maternal and Child Health Bureau of the Health Resources and Services Administration.

 

 Disclosure Statement

The authors declare no conflict of interest.


References

  1. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM: Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA 2010;303:242-249.
  2. Ludwig DS: Childhood obesity - the shape of things to come. N Engl J Med 2007;357:2325-2327.
  3. Alamian A, Paradis G: Clustering of chronic disease behavioral risk factors in Canadian children and adolescents. Prev Med 2009;48:493-499.
  4. Ullrich-French SC, Power TG, Daratha KB, Bindler RC, Steele MM: Examination of adolescents' screen time and physical fitness as independent correlates of weight status and blood pressure. J Sports Sci 2010;28:1189-1196.
  5. Haug E, Rasmussen M, Samdal O, Iannotti R, Kelly C, Borraccino A, Vereecken C, Melkevik O, Lazzeri G, Giacchi M, Ercan O, Due P, Ravens-Sieberer U, Currie C, Morgan A, Ahluwalia N; HBSC Obesity Writing Group: Overweight in school-aged children and its relationship with demographic and lifestyle factors: results from the WHO-Collaborative Health Behaviour in School-aged Children (HBSC) Study. Int J Public Health 2009;54:167-179.
  6. Haines J, Neumark-Sztainer D, Wall M, Story M: Personal, behavioral, and environmental risk and protective factors for adolescent overweight. Obesity (Silver Spring) 2007;15:2748-2760.
  7. Farhat T, Iannotti RJ, Simons-Morton BG: Overweight, obesity, youth, and health-risk behaviors. Am J Prev Med 2010;38:258-267.
  8. Dhariwal M, Rasmussen M, Holstein BE: Body mass index and smoking: cross-sectional study of a representative sample of adolescents in Denmark. Int J Public Health 2010;55:307-314.
  9. Potter BK, Pederson LL, Chan SSH, Aubut JAL, Koval JJ: Does a relationship exist between body weight, concerns about weight, and smoking among adolescents? An integration of the literature with an emphasis on gender. Nicotine Tob Res 2004;6:397-425.
  10. Janssen I, Katzmarzyk PT, Boyce WF, Vereecken C, Mulvihill C, Roberts C, Currie C, Pickett W; Health Behaviour in School-Aged Children Obesity Working Group: Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obes Rev 2005;6:123-132.
  11. Paxton SJ, Eisenberg ME, Neumark-Sztainer D: Prospective predictors of body dissatisfaction in adolescent girls and boys: a five-year longitudinal study. Dev Psychol 2006;42:888-899.
  12. Ali MM, Fang H, Rizzo JA: Body weight, self-perception and mental health outcomes among adolescents. J Ment Health Policy Econ 2010;13:53-63.

    External Resources

  13. Muennig P, Jia H, Lee R, Lubetkin E: I think therefore I am: perceived ideal weight as a determinant of health. Am J Public Health 2008;98:501-506.
  14. Nieri T, Kulis S, Keith VM, Hurdle D: Body image, acculturation, and substance abuse among boys and girls in the Southwest. Am J Drug Alcohol Abuse 2005;31:617-639.
  15. ter Bogt TFM, van Dorsselaer SAFM, Monshouwer K, Verdurmen JEE, Engels RCME, Vollebergh WAM: Body mass index and body weight perception as risk factors for internalizing and externalizing problem behavior among adolescents. J Adolesc Health 2006;39:27-34.
  16. Iannotti RJ, Janssen I, Haug E, Kololo H, Annaheim B, Borraccino A; HBSC Physical Activity Focus Group: Interrelationships of adolescent physical activity, screen-based sedentary behaviour, and social and psychological health. Int J Public Health 2009;54(suppl 2):191-198.
  17. Stice E, Shaw HE: Role of body dissatisfaction in the onset and maintenance of eating pathology: a synthesis of research findings. J Psychosom Res 2002;53:985-993.
  18. Kelly AM, Wall M, Eisenberg ME, Story M, Neumark-Sztainer D: Adolescent girls with high body satisfaction: who are they and what can they teach us? J Adolesc Health 2005;37:391-396.
  19. Dupuy M, Godeau E, Vignes C, Ahluwalia N: Socio-demographic and lifestyle factors associated with overweight in a representative sample of 11-15 year olds in France: results from the WHO-Collaborative Health Behaviour in School-aged Children (HBSC) cross-sectional study. BMC Public Health 2011;11:442.
  20. Gavin AR, Simon GE, Ludman EJ: The association between obesity, depression, and educational attainment in women: the mediating role of body image dissatisfaction. J Psychosom Res 2010;69:573-581.
  21. Teixeira PJ, Silva MN, Coutinho SR, Palmeira AL, Mata J, Vieira PN, Carraça EV, Santos TC, Sardinha LB: Mediators of weight loss and weight loss maintenance in middle-aged women. Obesity (Silver Spring) 2010;18:725-735.
  22. Merten MJ, Williams AL, Shriver LH: Breakfast consumption in adolescence and young adulthood: parental presence, community context, and obesity. J Am Diet Assoc 2009;109:1384-1391.
  23. Szajewska H, Ruszczynski M: Systematic review demonstrating that breakfast consumption influences body weight outcomes in children and adolescents in Europe. Crit Rev Food Sci Nutr 2010;50:113-119.
  24. Lawler M, Nixon E: Body dissatisfaction among adolescent boys and girls: the effects of body mass, peer appearance culture and internalization of appearance ideals. J Youth Adolesc 2011;40:59-71.
  25. Havinghurst RJ: Developmental Tasks and Education. New York, NY, McKay, 1972.
  26. Sobal J: Social influences on body weight; in Brownell KD, Fairburn CF (eds): Eating Disorders and Obesity: A Comprehensive Handbook. New York, Guilford Press, 2004, pp 73-77.
  27. Polivy J, Herman CP: Sociocultural idealization of thin female body shapes: an introduction to the special issue on body image and eating disorders. J Soc Clin Psychol 2004;23:1-6.

    External Resources

  28. Krayer A, Ingledew DK, Iphofen R: Social comparison and body image in adolescence: a grounded theory approach. Health Educ Res 2008;23:892-903.
  29. Compas BE, Connor-Smith JK, Saltzman H, Thomsen AH, Wadsworth ME: Coping with stress during childhood and adolescence: problems, progress, and potential in theory and research. Psychol Bull 2001;127:87-127.
  30. Chen JL, Kennedy C: Cultural variations in children's coping behaviour, TV viewing time, and family functioning. Int Nurs Rev 2005;52:183-195.
  31. Hoffmann JP, Su SS: Stressful life events and adolescent substance use and depression: conditional and gender differentiated effects. Subst Use Misuse 1998;33:2219-2262.
  32. Faith MS, Leone MA, Ayers TS, Heo M, Pietrobelli A: Weight criticism during physical activity, coping skills, and reported physical activity in children. Pediatrics 2002;110:e23.
  33. Goodman E, Hinden BR, Khandelwal S: Accuracy of teen and parental reports of obesity and body mass index. Pediatrics 2000;106:52-58.

    External Resources

  34. Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, Wei R, Curtin LR, Roche AF, Johnson CL: 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat 11 2002;246:1-190.

    External Resources

  35. Orbach I, Mikulincer M: The body investment scale: construction and validation of a body experience scale. Psychological Assess 1998;10:415-425.

    External Resources

  36. Lamis DA, Malone PS, Langhinrichsen-Rohling J, Ellis TE: Body investment, depression, and alcohol use as risk factors for suicide proneness in college students. Crisis 2010;31:118-127.
  37. Currie C, Molcho M, Boyce W, Holstein B, Torsheim T, Richter M: Researching health inequalities in adolescents: the development of the Health Behaviour in School-Aged Children (HBSC) family affluence scale. Soc Sci Med 2008;66:1429-1436.
  38. Baron RM, Kenny DA: The moderator-mediator variable distinction in social psychological research - conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986;51:1173-1182.
  39. Stead M, McDermott L, MacKintosh AM, Adamson A: Why healthy eating is bad for young people's health: identity, belonging and food. Soc Sci Med 2011;72:1131-1139.
  40. Puhl RM, Brownell KD: Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity (Silver Spring) 2006;14:1802-1815.
  41. Erickson JD, Patterson JM, Wall M, Neumark-Sztainer D: Risk behaviors and emotional well-being in youth with chronic health conditions. Child Health Care 2005;34:181-192.

    External Resources

  42. Steele CA, Kalnins IV, Jutai JW, Stevens SE, Bortolussi JA, Biggar WD: Lifestyle health behaviours of 11- to 16-year-old youth with physical disabilities. Health Educ Res 1996;11:173-186.

    External Resources

  

Author Contacts

Tilda Farhat, Ph.D., M.P.H.
Center to Reduce Cancer Health Disparities
National Cancer Institute, National Institutes of Health
6909 Medical Center Drive, Bethesda, MD 20892 (USA)
farhatti@mail.nih.gov

  

Article Information

Received: December 6, 2011
Accepted: August 10, 2013
Published online: December 20, 2013
Number of Print Pages : 14
Number of Figures : 0, Number of Tables : 5, Number of References : 42

  

Publication Details

Obesity Facts (The European Journal of Obesity)

Vol. 7, No. 1, Year 2014 (Cover Date: February 2014)

Journal Editor: Hebebrand J. (Essen)
ISSN: 1662-4025 (Print), eISSN: 1662-4033 (Online)

For additional information: http://www.karger.com/OFA


Open Access License / Drug Dosage / Disclaimer

Open Access License: This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Background/Aims: To examine whether body image mediates the association between overweight/obesity and chronic disease-related health practices (CDRHP), including lack of physical activity (PA), infrequent breakfast consumption (IBC), screen-based media use (SBM), and smoking. Methods: The 2006 Health Behaviors in School-Age Children survey was administered to a nationally representative sample of US students (n = 8,028) in grades 6-10 (mean age = 14.3 years). Outcome variables included self-reported measures of PA, SBM, IBC, and smoking. Body image was assessed with 5 items from the Body Investment Scale (α = 0.87) asking for agreement/disagreement with statements about one's body. Stratifying on gender, an initial regression model estimated the association between overweight/obesity and CDRHP. Mediation models that included body image were then compared to the initial model to determine the role of body image in the relationship between overweight/obesity and CDRHP. Results: Among boys, body image mediated the relationships of overweight/obesity with SBM, and of obesity with IBC. Among girls, it mediated the relationships of obesity with PA, IBC, and smoking, and of overweight with SBM. Conclusion: As the prevalence of overweight/obesity among adolescent boys and girls remains high, efforts to improve their body image could result in less frequent engagement in CDRHP.

© 2013 S. Karger GmbH, Freiburg


  

Author Contacts

Tilda Farhat, Ph.D., M.P.H.
Center to Reduce Cancer Health Disparities
National Cancer Institute, National Institutes of Health
6909 Medical Center Drive, Bethesda, MD 20892 (USA)
farhatti@mail.nih.gov

  

Article Information

Received: December 6, 2011
Accepted: August 10, 2013
Published online: December 20, 2013
Number of Print Pages : 14
Number of Figures : 0, Number of Tables : 5, Number of References : 42

  

Publication Details

Obesity Facts (The European Journal of Obesity)

Vol. 7, No. 1, Year 2014 (Cover Date: February 2014)

Journal Editor: Hebebrand J. (Essen)
ISSN: 1662-4025 (Print), eISSN: 1662-4033 (Online)

For additional information: http://www.karger.com/OFA


Article / Publication Details

First-Page Preview
Abstract of Original Article

Received: 12/6/2011
Accepted: 8/10/2013
Published online: 12/20/2013
Issue release date: February 2014

Number of Print Pages: 0
Number of Figures: 0
Number of Tables: 0

ISSN: 1662-4025 (Print)
eISSN: 1662-4033 (Online)

For additional information: http://www.karger.com/OFA


Open Access License / Drug Dosage

Open Access License: This is an Open Access article licensed under the terms of the Creative Commons Attribution-NonCommercial 3.0 Unported license (CC BY-NC) (www.karger.com/OA-license), applicable to the online version of the article only. Distribution permitted for non-commercial purposes only.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM: Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA 2010;303:242-249.
  2. Ludwig DS: Childhood obesity - the shape of things to come. N Engl J Med 2007;357:2325-2327.
  3. Alamian A, Paradis G: Clustering of chronic disease behavioral risk factors in Canadian children and adolescents. Prev Med 2009;48:493-499.
  4. Ullrich-French SC, Power TG, Daratha KB, Bindler RC, Steele MM: Examination of adolescents' screen time and physical fitness as independent correlates of weight status and blood pressure. J Sports Sci 2010;28:1189-1196.
  5. Haug E, Rasmussen M, Samdal O, Iannotti R, Kelly C, Borraccino A, Vereecken C, Melkevik O, Lazzeri G, Giacchi M, Ercan O, Due P, Ravens-Sieberer U, Currie C, Morgan A, Ahluwalia N; HBSC Obesity Writing Group: Overweight in school-aged children and its relationship with demographic and lifestyle factors: results from the WHO-Collaborative Health Behaviour in School-aged Children (HBSC) Study. Int J Public Health 2009;54:167-179.
  6. Haines J, Neumark-Sztainer D, Wall M, Story M: Personal, behavioral, and environmental risk and protective factors for adolescent overweight. Obesity (Silver Spring) 2007;15:2748-2760.
  7. Farhat T, Iannotti RJ, Simons-Morton BG: Overweight, obesity, youth, and health-risk behaviors. Am J Prev Med 2010;38:258-267.
  8. Dhariwal M, Rasmussen M, Holstein BE: Body mass index and smoking: cross-sectional study of a representative sample of adolescents in Denmark. Int J Public Health 2010;55:307-314.
  9. Potter BK, Pederson LL, Chan SSH, Aubut JAL, Koval JJ: Does a relationship exist between body weight, concerns about weight, and smoking among adolescents? An integration of the literature with an emphasis on gender. Nicotine Tob Res 2004;6:397-425.
  10. Janssen I, Katzmarzyk PT, Boyce WF, Vereecken C, Mulvihill C, Roberts C, Currie C, Pickett W; Health Behaviour in School-Aged Children Obesity Working Group: Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obes Rev 2005;6:123-132.
  11. Paxton SJ, Eisenberg ME, Neumark-Sztainer D: Prospective predictors of body dissatisfaction in adolescent girls and boys: a five-year longitudinal study. Dev Psychol 2006;42:888-899.
  12. Ali MM, Fang H, Rizzo JA: Body weight, self-perception and mental health outcomes among adolescents. J Ment Health Policy Econ 2010;13:53-63.

    External Resources

  13. Muennig P, Jia H, Lee R, Lubetkin E: I think therefore I am: perceived ideal weight as a determinant of health. Am J Public Health 2008;98:501-506.
  14. Nieri T, Kulis S, Keith VM, Hurdle D: Body image, acculturation, and substance abuse among boys and girls in the Southwest. Am J Drug Alcohol Abuse 2005;31:617-639.
  15. ter Bogt TFM, van Dorsselaer SAFM, Monshouwer K, Verdurmen JEE, Engels RCME, Vollebergh WAM: Body mass index and body weight perception as risk factors for internalizing and externalizing problem behavior among adolescents. J Adolesc Health 2006;39:27-34.
  16. Iannotti RJ, Janssen I, Haug E, Kololo H, Annaheim B, Borraccino A; HBSC Physical Activity Focus Group: Interrelationships of adolescent physical activity, screen-based sedentary behaviour, and social and psychological health. Int J Public Health 2009;54(suppl 2):191-198.
  17. Stice E, Shaw HE: Role of body dissatisfaction in the onset and maintenance of eating pathology: a synthesis of research findings. J Psychosom Res 2002;53:985-993.
  18. Kelly AM, Wall M, Eisenberg ME, Story M, Neumark-Sztainer D: Adolescent girls with high body satisfaction: who are they and what can they teach us? J Adolesc Health 2005;37:391-396.
  19. Dupuy M, Godeau E, Vignes C, Ahluwalia N: Socio-demographic and lifestyle factors associated with overweight in a representative sample of 11-15 year olds in France: results from the WHO-Collaborative Health Behaviour in School-aged Children (HBSC) cross-sectional study. BMC Public Health 2011;11:442.
  20. Gavin AR, Simon GE, Ludman EJ: The association between obesity, depression, and educational attainment in women: the mediating role of body image dissatisfaction. J Psychosom Res 2010;69:573-581.
  21. Teixeira PJ, Silva MN, Coutinho SR, Palmeira AL, Mata J, Vieira PN, Carraça EV, Santos TC, Sardinha LB: Mediators of weight loss and weight loss maintenance in middle-aged women. Obesity (Silver Spring) 2010;18:725-735.
  22. Merten MJ, Williams AL, Shriver LH: Breakfast consumption in adolescence and young adulthood: parental presence, community context, and obesity. J Am Diet Assoc 2009;109:1384-1391.
  23. Szajewska H, Ruszczynski M: Systematic review demonstrating that breakfast consumption influences body weight outcomes in children and adolescents in Europe. Crit Rev Food Sci Nutr 2010;50:113-119.
  24. Lawler M, Nixon E: Body dissatisfaction among adolescent boys and girls: the effects of body mass, peer appearance culture and internalization of appearance ideals. J Youth Adolesc 2011;40:59-71.
  25. Havinghurst RJ: Developmental Tasks and Education. New York, NY, McKay, 1972.
  26. Sobal J: Social influences on body weight; in Brownell KD, Fairburn CF (eds): Eating Disorders and Obesity: A Comprehensive Handbook. New York, Guilford Press, 2004, pp 73-77.
  27. Polivy J, Herman CP: Sociocultural idealization of thin female body shapes: an introduction to the special issue on body image and eating disorders. J Soc Clin Psychol 2004;23:1-6.

    External Resources

  28. Krayer A, Ingledew DK, Iphofen R: Social comparison and body image in adolescence: a grounded theory approach. Health Educ Res 2008;23:892-903.
  29. Compas BE, Connor-Smith JK, Saltzman H, Thomsen AH, Wadsworth ME: Coping with stress during childhood and adolescence: problems, progress, and potential in theory and research. Psychol Bull 2001;127:87-127.
  30. Chen JL, Kennedy C: Cultural variations in children's coping behaviour, TV viewing time, and family functioning. Int Nurs Rev 2005;52:183-195.
  31. Hoffmann JP, Su SS: Stressful life events and adolescent substance use and depression: conditional and gender differentiated effects. Subst Use Misuse 1998;33:2219-2262.
  32. Faith MS, Leone MA, Ayers TS, Heo M, Pietrobelli A: Weight criticism during physical activity, coping skills, and reported physical activity in children. Pediatrics 2002;110:e23.
  33. Goodman E, Hinden BR, Khandelwal S: Accuracy of teen and parental reports of obesity and body mass index. Pediatrics 2000;106:52-58.

    External Resources

  34. Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, Wei R, Curtin LR, Roche AF, Johnson CL: 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat 11 2002;246:1-190.

    External Resources

  35. Orbach I, Mikulincer M: The body investment scale: construction and validation of a body experience scale. Psychological Assess 1998;10:415-425.

    External Resources

  36. Lamis DA, Malone PS, Langhinrichsen-Rohling J, Ellis TE: Body investment, depression, and alcohol use as risk factors for suicide proneness in college students. Crisis 2010;31:118-127.
  37. Currie C, Molcho M, Boyce W, Holstein B, Torsheim T, Richter M: Researching health inequalities in adolescents: the development of the Health Behaviour in School-Aged Children (HBSC) family affluence scale. Soc Sci Med 2008;66:1429-1436.
  38. Baron RM, Kenny DA: The moderator-mediator variable distinction in social psychological research - conceptual, strategic, and statistical considerations. J Pers Soc Psychol 1986;51:1173-1182.
  39. Stead M, McDermott L, MacKintosh AM, Adamson A: Why healthy eating is bad for young people's health: identity, belonging and food. Soc Sci Med 2011;72:1131-1139.
  40. Puhl RM, Brownell KD: Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity (Silver Spring) 2006;14:1802-1815.
  41. Erickson JD, Patterson JM, Wall M, Neumark-Sztainer D: Risk behaviors and emotional well-being in youth with chronic health conditions. Child Health Care 2005;34:181-192.

    External Resources

  42. Steele CA, Kalnins IV, Jutai JW, Stevens SE, Bortolussi JA, Biggar WD: Lifestyle health behaviours of 11- to 16-year-old youth with physical disabilities. Health Educ Res 1996;11:173-186.

    External Resources