Self-esteem and obesity in children and adolescents: a literature review

Special considerations in childhood and adolescent obesity

Child and adolescent obesity is increasingly prevalent in westernized countries. It is associated with significant medical and psychosocial co-morbidities that are both immediate and long-term. While genetic factors influence the susceptibility of a given child to an obesity-conducive environment, the current epidemic is due to massive environmental change over the past few decades leading to a rise in sedentary pursuits, a decrease in physical activity and increased energy intake. Effective management requires a family-focused, developmentally sensitive, behavioural management approach that addresses, for example, eating habits, incidental activity and television viewing. Prevention of childhood obesity will ultimately require multi-faceted, large-scale interventions.

Childhood overweight and academic performance: national study of kindergartners and first-graders

OBJECTIVE

To examine the association between children's overweight status in kindergarten and their academic achievement in kindergarten and first grade.

RESEARCH METHODS AND PROCEDURES

The data analyzed consisted of 11,192 first time kindergartners from the Early Childhood Longitudinal Study, a nationally representative sample of kindergartners in the U.S. in 1998. Multivariate regression techniques were used to estimate the independent association of overweight status with children's math and reading standardized test scores in kindergarten and grade 1. We controlled for socioeconomic status, parent-child interaction, birth weight, physical activity, and television watching.

RESULTS

Overweight children had significantly lower math and reading test scores compared with non-overweight children in kindergarten. Both groups were gaining similarly on math and reading test scores, resulting in significantly lower test scores among overweight children at the end of grade 1. However, these differences, except for boys' math scores at baseline (difference = 1.22 points, p = 0.001), became insignificant after including socioeconomic and behavioral variables, indicating that overweight is a marker but not a causal factor. Race/ethnicity and mother's education were stronger predictors of test score gains or levels than overweight status.

DISCUSSION

Significant differences in test scores by overweight status at the beginning of kindergarten and the end of grade 1 can be explained by other individual characteristics, including parental education and the home environment. However, overweight is more easily observable by other students compared with socioeconomic characteristics, and its significant (unadjusted) association with worse academic performance can contribute to the stigma of overweight as early as the first years of elementary school.

Psychiatric aspects of child and adolescent obesity: a review of the past 10 years

OBJECTIVE

To review the past 10 years of published research on psychiatric aspects of child and adolescent obesity and highlight information mental health professionals need for preventing obesity in youths and diagnosing and treating it.

METHOD

Researchers performed computerized and manual searches of the literature and summarized the most relevant articles.

RESULTS

The growing epidemic of child and adolescent obesity deserves attention for its immediate mental health and long-term medical complications. Mental health professionals working with obese youths should be aware of recent advances in neuroscience, genetics, and etiologies associated with obesity. Those who assess and treat obese youth should view obesity as a chronic disease. Currently, no approved pharmacological or surgical approaches exist to treat childhood obesity.

CONCLUSIONS

Health care providers should focus on modest weight-loss goals that correlate with significant health benefits. The most effective treatments include substantial parental involvement. Mental health professionals should help obese children build self-esteem to help them lead full lives regardless of weight.

Child and adolescent obesity in the 21st century: an Australian perspective

The early 21st century has seen the development of a global epidemic of obesity in both developed and developing countries. In Australia at least one in five children and adolescents are overweight or obese, with rapid rises in prevalence apparently continuing. Similar trends are seen in other countries. Child and adolescent obesity is associated with both immediate and long-term medical and psychosocial problems, including a clustering of risk factors for the development of cardiovascular disease and diabetes. Thus, obesity poses a major health problem for the paediatric population. Major environmental and societal changes have led to a decrease in physical activity, a rise in sedentary behaviour and the consumption of high fat and high-energy foods, all in turn influencing the development of obesity. Effective management involves a multimodal approach with a developmentally aware approach, involvement of the family, a focus on healthy food choices, incorporation of physical activity and a decrease in sedentary behaviour all being important. Ultimately, however, the obesity epidemic requires a major focus on primary prevention. Australia has a national strategy for the prevention of overweight and obesity that depends upon intersectoral and intergovernmental cooperation, supported by adequate resourcing and significant community ownership.

Children's weight-loss camps: psychological benefit or jeopardy?

OBJECTIVES

To investigate the change in body image, self-esteem, and worries in obese adolescents attending a residential, weight-loss camp.

DESIGN

A longitudinal intervention study, with a nonintervention comparison group of lean adolescents.

PARTICIPANTS

A total of 57 obese adolescents (age: 13,11; BMI: 32.6 kg/m(2)) and 38 normal weight comparison adolescents.

MEASURES

Self-esteem, salience of weight-related issues, body shape preference, weight and height at the start, and end of the weight-loss camp (mean stay: 4 weeks).

RESULTS

The obese adolescents lost 5.6 kg, reduced their BMI by 2.1 kg/m(2), and BMI s.d. score by 0.28 while comparison children gained weight. Body shape dissatisfaction significantly decreased and self-esteem increased on measures of global self-worth, athletic competence, and physical appearance, in the camp attendees. This improvement took place without any exacerbation of existing worries about appearance or weight.

CONCLUSIONS

While obese adolescents had lower self-worth and greater body dissatisfaction relative to the comparison children at the start of the camp, the intervention improved their psychological state. Greater weight loss was associated with greater psychological improvement, indicating the value of the intervention and the relevance of psychological change in effective treatment.

Survey of physician attitudes and practices related to pediatric obesity

The purpose of this study was to survey physicians regarding their attitudes and practices related to the treatment of pediatric obesity in a primary care setting. Surveys were sent to physicians who were members of the American Academy of Pediatrics and the American Academy of Family Physicians practicing in the Southern New England area (Connecticut, Massachusetts, and Rhode Island). The 14-item survey consisted of three main areas of focus: attitudes toward obesity, treatment and referral approaches, and barriers to addressing weight concerns in children and adolescents. Physicians estimated that 27.7% of their adolescent and 23% of their child patients are overweight. The frequency with which physicians address weight issues with both child and adolescent patients appears to increase incrementally with the patient's level of overweight. When addressing obesity, one fourth of physicians think that they are not at all or only slightly competent, while 20% report feeling not at all or only slightly comfortable. These findings suggest that physicians would benefit from additional training and education regarding safe and efficacious intervention strategies for pediatric obesity, to effectively integrate the discussion of weight issues into the primary care setting.

Ways of coping with obesity stigma: review and conceptual analysis

There is clear documentation of bias and discrimination aimed at overweight persons, but less is known about methods individuals use to cope with weight stigma. This paper provides an analysis of such methods, integrating work on weight stigma with what is known from other relevant areas (e.g., race and gender bias). Multiple means of coping have been studied, ranging from attempts to change the stigmatizing condition (losing weight) to taking pride in the condition and mobilizing social action to prevent discrimination. The most promising areas for future research, methodological challenges, and the importance of individual difference and situational factors as moderating variables are discussed.

Maternal gestational diabetes, birth weight, and adolescent obesity

OBJECTIVE

Obesity increases risk of many adverse outcomes, but its early origins are obscure. Gestational diabetes mellitus (GDM) reflects a metabolically altered fetal environment associated with high birth weight, itself associated with later obesity. Previous studies of GDM and offspring obesity, however, have been few and conflicting. The objectives of this study were to examine associations of birth weight and GDM with adolescent body mass index (BMI) and to determine the extent to which the effect of GDM is explained by its influence on birth weight or by maternal adiposity.

METHODS

We conducted a survey of 7981 girls and 6900 boys, 9 to 14 years of age, who are participants in the Growing Up Today Study, a US nationwide study of diet, activity, and growth. In 1996, participants reported height, weight, diet, activity, and other variables by self-administered mailed questionnaire. We linked these data with information reported by their mothers, participants in the Nurses' Health Study II, including GDM, height, current weight, and child's birth weight. We excluded births <34 weeks' gestation and mothers who had preexisting diabetes. We defined overweight as BMI (kg/m(2)) >95th percentile, and at risk for overweight as 85th to 95th percentile, for age and gender from US national data.

RESULTS

Mean birth weight was 3.4 kg for girls and 3.6 kg for boys. Among the 465 subjects whose mothers had GDM, 17.1% were at risk for overweight and 9.7% were overweight in early adolescence. In the group without maternal diabetes, these estimates were 14.2% and 6.6%, respectively. In multiple logistic regression analysis, controlling for age, gender, and Tanner stage, the odds ratio for adolescent overweight for each 1-kg increment in birth weight was 1.4 (95% confidence interval: 1.2-1.6). Adjustment for physical activity, television watching, energy intake, breastfeeding duration, mother's BMI, and other maternal and family variables reduced the estimate to 1.3 (1.1-1.5). For offspring of mothers with GDM versus no diabetes, the odds ratio for adolescent overweight was 1.4 (1.1-2.0), which was unchanged after controlling for energy balance and socioeconomic factors. Adjustment for birth weight slightly attenuated the estimate (1.3; 0.9-1.9); adjustment for maternal BMI reduced the odds ratio to 1.2 (0.8-1.7).

CONCLUSIONS

Higher birth weight predicted increased risk of overweight in adolescence. Having been born to a mother with GDM was also associated with increased adolescent overweight. However, the effect of GDM on offspring obesity seemed only partially explained by its influence on birth weight, and adjustment for mother's own BMI attenuated the GDM associations. Our results only modestly support a causal role of altered maternal-fetal glucose metabolism in the genesis of obesity in the offspring. Alternatively, GDM may program risk for a postnatal insult leading to obesity, or it may merely be a risk marker, not in the causal pathway.

Childhood obesity: a societal problem to solve

In contrast to other threats to American children's health, the treatment and prevention of childhood obesity are considered the responsibility of individual children and their parents. This pressure exists in the context of the societal stigmatization of overweight children and the powerful environmental inducements aimed directly at children to eat nutritionally poor foods. Parents of overweight children are left in the difficult position of fearing the social and health consequences of their child's obesity, and fighting a losing battle against the omnipotent presence of the media and constant exposure to unhealthy foods. This paper brings together several literatures to provide a comprehensive examination of the major challenges facing obese children and their families. In particular, this paper documents the extent of stigmatization towards overweight children and reviews evidence of the conflicting advice given to parents about how to help children develop healthful eating in the face of biological and learned food preferences. We conclude with a call for a shift in thinking about the role of our society in the aetiology, treatment and prevention of childhood obesity.

Change in the prevalence of overweight and obesity among young Australians, 1969-1997

BACKGROUND

Effective public policy requires information on the prevalence of overweight and obesity.

OBJECTIVE

We determined changes in the population prevalence of overweight and obesity among young Australians (aged 7-15 y) from 1969 to 1985 to 1997.

DESIGN

Data from 5 independent population surveys were analyzed: the Australian Youth Fitness Survey, 1969; the Australian Health and Fitness Survey, 1985; the South Australian Schools Fitness and Physical Activity Survey, 1997; the New South Wales Schools Fitness and Physical Activity Survey, 1997; and the Health of Young Victorians Study, 1997. Measured body mass index was used as the index of adiposity, and recently published body mass index cutoff values were used to categorize each subject as nonoverweight, overweight, obese, or either overweight or obese.

RESULTS

For 1985-1997, the population prevalence of overweight increased by 60-70%, obesity increased 2-4-fold, and the combined overweight and obesity categories doubled. The findings were consistent across data sets and between the sexes. For 1969-1985, there was no change in the prevalence of overweight or obesity among girls, but among boys the prevalence of overweight increased by 35%, the prevalence of obesity trebled, and the prevalence of overweight and obesity combined increased by 60%.

CONCLUSIONS

The data show that in 1985-1997, the prevalence of overweight and obesity combined doubled and that of obesity trebled among young Australians, but the increase over the previous 16 y was far smaller. These results should increase our sense of urgency in identifying and implementing effective responses to this major threat to public health.

Childhood and adulthood risk factors for socio-economic differentials in psychological distress: evidence from the 1958 British birth cohort

Social inequalities in psychological status have been attributed to health selection and to social causation. We used data from the 1958 British birth cohort, followed over three decades, to identify causes of inequality in adulthood. Psychological status prior to labour market entry influenced inter-generational mobility, but selection effects were weaker for intra-generational mobility, between age 23 and 33. However, selection failed to account for social differences in risk of distress of approximately threefold in classes IV&V compared with I&II. Both childhood and adult life factors appeared to contribute to the development of inequalities. The principal childhood factors were ability at age 7 for both sexes and adverse environment (institutional care for men and low class for women). Adult life factors varied, with stronger effects for work factors (job strain and insecurity) for men and qualifications on leaving school, early child-bearing and financial hardship for women. Gradients in psychological distress reflect the cumulative effect of multiple adversities experienced from childhood.

A prospective study of the role of depression in the development and persistence of adolescent obesity

BACKGROUND

Adolescent obesity is a strong predictor of adult obesity, and adult obesity has been associated with depression, especially in women. Studies have also suggested an association between depression in adolescence and higher body mass index (BMI) in adulthood. Whether depression leads to obesity or obesity causes depression is unclear.

OBJECTIVE

To determine in longitudinal analyses whether depressed mood predicts the development and persistence of obesity in adolescents.

METHODS

A prospective cohort study of 9374 adolescents in grades 7 through 12 who completed in-home interviews for the National Longitudinal Study of Adolescent Health. Assessments were made at baseline (1995) and at follow-up 1 year later. Depressed mood was assessed with the Center for Epidemiologic Studies Depression Scale. BMI (kg/m2) was calculated from self-reported height and weight. BMI percentiles and z scores were computed using the 2000 Centers for Disease Control and Prevention growth charts. Obesity was defined as BMI > or =95th percentile, overweight as BMI > or =85th percentile and <95th percentile, and normal weight as BMI <85th percentile. A parental respondent gave information on household income, parental education, and parental obesity.

RESULTS

At baseline, 12.9% were overweight, 9.7% were obese, and 8.8% had depressed mood. Baseline depression was not significantly correlated with baseline obesity. Among the 9.7% who were obese at follow-up, 79.6% were obese at baseline, 18.6% were overweight at baseline, and 1.8% were normal weight at baseline. Having depressed mood at baseline independently predicted obesity at follow-up (odds ratio: 2.05; 95% confidence interval: 1.18, 3.56) after controlling for BMI z score at baseline, age, race, gender, parental obesity, number of parents in the home, and family socioeconomic status. This finding persisted after controlling further for the adolescents' report of smoking, self-esteem, delinquent behavior (conduct disorder), and physical activity. After controlling for all these same factors, depressed mood at baseline also predicted obesity at follow-up among those not obese at baseline (odds ratio: 2.05; 95% confidence interval: 1.04, 4.06) and follow-up BMI z score among those obese at baseline (beta = 0.11; standard error beta = 0.05). In contrast, baseline obesity did not predict follow-up depression.

CONCLUSIONS

Depressed adolescents are at increased risk for the development and persistence of obesity during adolescence. Understanding the shared biological and social determinants linking depressed mood and obesity may inform the prevention and treatment of both disorders.

Economic burden of obesity in youths aged 6 to 17 years: 1979-1999

OBJECTIVE

To examine the trend of obesity-associated diseases in youths and related economic costs.

METHODS

Using a multiyear data file of the National Hospital Discharge Survey, 1979-1999, we analyzed the changes in obesity-associated diseases and economic costs in youths (6-17 years of age) over time. Diabetes, obesity, sleep apnea, and gallbladder disease were examined to explore the trend of the disease burden. Other obesity-associated diseases for which obesity was listed as a secondary diagnosis were also analyzed. Obesity-associated hospital costs were estimated from the discharges with obesity listed as a principal or secondary diagnosis.

RESULTS

From 1979-1981 to 1997-1999, the percentage of discharges with obesity-associated diseases increased. The discharges of diabetes nearly doubled (from 1.43% to 2.36%), obesity and gallbladder diseases tripled (0.36% to 1.07% and 0.18% to 0.59%, respectively), and sleep apnea increased fivefold (0.14% to 0.75%). Ninety-six percent of discharges with a diagnosis of obesity listed obesity as a secondary diagnosis. Asthma and some mental disorders were the most common principal diagnoses when obesity was listed as a secondary diagnosis. Obesity-associated annual hospital costs (based on 2001 constant US dollar value) increased more than threefold; from $35 million (0.43% of total hospital costs) during 1979-1981 to $127 million (1.70% of total hospital costs) during 1997-1999.

CONCLUSIONS

Among all hospital discharges, the proportion of discharges with obesity-associated diseases has increased dramatically in the past 20 years. This increase has led to a significant growth in economic costs. These findings may reflect the impact of increasing prevalence and severity of obesity. Diet and physical activity interventions should be developed for weight loss and prevention of weight gain in youths.

Secular trends in overweight and obesity among Finnish adolescents in 1977-1999

OBJECTIVE

To study the trends in overweight and obesity among Finnish adolescents in 1977-1999.

DESIGN

Mailed surveys every other year.

SUBJECTS

Nationally representative samples of 12, 14, 16 and 18-y-olds (n = 64,147, response rate 78.9%).

METHODS

Overweight and obesity were measured by body mass index (BMI) and relative weight (RW) based on self-reported height and weight. BMI > or = the 85th percentile cut-off point for BMI in each age- and sex-specific group in the entire data set was considered as overweight, and BMI > or = 95th percentile cut-off point as obesity. RW > or = 110% and > or = 120%, calculated as the individual's weight divided by the mean weight in each age- and sex-specific height percentile group in the entire data set, were considered as overweight and obesity, respectively. The trends in overweight and obesity are described by the change in the 85th and 95th percentile cut-off points of BMI over time. The prevalence of overweight and obesity is also reported using BMI reference values recommended for international comparisons. Because of the similarity of the BMI and the RW criteria in classifying adolescents as overweight and obese, only results based on BMI are presented.

RESULTS

Overweight and obesity increased linearly in all sex and age groups from 1977 to 1999. Depending on the age group, the average increase in the 85th percentile cut-off point of the BMI per 10 y was 0.6-1.1 kg/m2 in boys and 0.3-0.7 kg/m2 in girls. The 95th percentile cut-off point of the BMI for boys and girls increased by 1.1-1.6 kg/m2 and by 0.6-1.0 kg/m2 per 10 y, respectively. In boys, the increase in overweight and obesity was largest in the two youngest age groups. In girls, the increase in overweight was largest in the oldest age group, and that of obesity both in the 14 and 18-y-olds. Overweight and obesity increased more in boys than in girls in all age groups except in the 18-y-olds among whom the increase was similar in both sexes. Examination of the entire BMI distribution showed that there was little or no change over time at the lower (5th, 15th) and middle (50th) percentiles, but increasing differences at the upper end of the distribution, the increases in the 95th percentile being even more marked than those in the 85th percentile curves. According to international reference values, the age-standardized prevalence of overweight increased in boys from 7.2 to 16.7%, and in girls from 4.0 to 9.8%, between 1977 and 1999. The prevalence of obesity in boys was 1.1% in 1977 and 2.7% in 1999, and in girls 0.4 and 1.4%, respectively.

CONCLUSION

Overweight and obesity increased remarkably among Finnish adolescents from 1977 to 1999. The changes concentrated at the upper end of the BMI distribution, suggesting that factors behind this development have influenced only a part of the adolescent population.

Preventing pediatric obesity: assessment and management in the primary care setting

PURPOSE

To review the literature on and discuss the role of the primary care provider in assessing and managing overweight children before they become obese.

DATA SOURCES

Selected research, national guidelines and recommendations, and the professional experience of the authors.

CONCLUSIONS

The focus of primary care involves early detection and family interventions that are designed for lifestyle modifications, specifically for improved nutrition and an increase in regular physical activity, to achieve optimal child health. Early identification and management of children who exceed a healthy weight for height, gender, and age will prevent the increasing incidence of pediatric obesity. Early prevention and management of pediatric overweight and obesity will also decrease the potential for associated medical and psychosocial problems.

IMPLICATIONS FOR PRACTICE

Pediatric obesity has risen dramatically in the United States during the last two decades; it is a significant child health problem that is preventable and largely under-diagnosed and under-treated. It is essential to discuss prevention of obesity with parents at every well-child visit; treatment should be initiated when patterns of weight gain exceed established percentiles for increasing height for age and gender.

Pediatric obesity

Pediatric obesity can be defined as BMI > 95th percentile for age and sex from large surveys that were carried out in the past. Using these cut points, over 10% of all children and adolescents are obese, and another 10% are overweight (BMI > 85th percentile). Obesity in childhood is associated with many immediate consequences, including orthopedic, neurologic, pulmonary, gastroenterologic, endocrinologic, metabolic, and cardiovascular disorders. Psychosocial and economic problems also are seen in obese adolescents. Long-term consequences of pediatric obesity include risks for cardiovascular disease and death that are independent of adult body weight. The differential diagnosis of pediatric obesity includes many multi-system genetic syndromes and a limited number of endocrine disorders that include abnormalities in the leptin signaling pathway, but most children with excess body weight do not have an established diagnosis. Treatment is best carried out at specialized centers, and usually involves a program of behavioral modification, caloric restriction, increased activity, and decreased sedentary behaviors. Medication for pediatric obesity cannot be recommended at present outside the context of clinical trials. Gastric bypass surgery is effective, but should be considered a last resort for the child with life-threatening complications of obesity.

Quality of life, overweight, and body fat distribution in middle-aged men

Measurements of obesity [body mass index (BMI)] and body fat distribution [waist-to-hip ratio (WHR)] were analyzed in 284 51-year-old men in relation to items about social, mental, and physical well-being from the Göteborg Quality of Life Instrument. Overweight participants (BMI > or = 25) reported a better home-family situation, appetite, and self-esteem, but decreased physical fitness and more pain in the legs compared with their leaner counterparts. Men with abdominal obesity (WHR > or = 1.0) experienced impaired health and physical fitness and lower self-esteem compared with those with WHR < 1.0. The abdominally obese participants were more often exhausted and experienced depressive symptoms. Abdominal pain was more frequent among those with WHR > or = 1.0. Overweight and abdominal obesity seem differently associated with social, mental, and physical well-being in men. Impaired quality of life may be causally related to the development of abdominal obesity; the mechanism involved might be increased cortisol secretion, which can redistribute body fat to central adipose tissue depots.

Interventions for weight loss and weight gain prevention among youth: current issues

The recent increase in the prevalence of paediatric obesity is one of the most pressing public health concerns today because of the immediate and long term health consequences associated with this often intractable disease. Efforts are currently being made to reduce the prevalence of paediatric obesity. Youth weight loss studies have produced significant long term results. Most of these programmes included behaviour modification, diet and exercise. Studies have suggested that lifestyle exercise programmes may produce the best long term results. Effective components of these programmes appear to be parental involvement, reduced intake of foods having high energy density and reductions in physical inactivity. Future weight loss studies need to determine the type, intensity, and duration of exercise that will produce acceptable adherence and consequent long term weight loss, and to ascertain the reinforcing factors that determine youth behaviour choice. Weight gain prevention interventions for youth are clearly in their infancy. This review describes 3 completed and 2 ongoing weight gain prevention trials. One study showed reductions in the prevalence of obesity among junior high school girls, but not among boys. Another study among elementary school students showed significant mean decreases in body mass index in boys and girls following an intervention specifically to reduce time spent viewing television. Whether these studies altered food intake or increased physical activity remains unclear. A combination of weight loss treatment and weight gain prevention strategies employed in parallel is likely to yield the greatest benefits. Development and testing of novel intervention strategies, using innovative behavioural approaches to increase the likelihood that children will adopt healthy dietary, physical activity, and sedentary behaviour patterns, holds great promise to significantly reduce the epidemic of obesity.

Social, educational, and psychological correlates of weight status in adolescents

OBJECTIVES

The purpose of this research was to examine the social, educational, and psychological correlates of weight status in an adolescent population. It was hypothesized that obese adolescents would differ on psychological, social, and educational variables compared with their non-overweight peers.

RESEARCH METHODS AND PROCEDURES

In this cross-sectional study, a population-based sample of 4742 male and 5201 female public school students in the 7th, 9th, and 11th grades responded anonymously to a classroom administered questionnaire. Body mass index was calculated from self-reported height and weight and categorized into four classes of weight status: underweight (<15th percentile), average weight (15th to 85th percentile), overweight (>85th to 95th percentile), and obese (>95th percentile). The questionnaire also included questions about social experiences, psychological well-being, educational experiences, and future goals. Associations of weight status with social, psychological, and educational variables and future goals were explored.

RESULTS

After adjustment for grade level, race, and parental socioeconomic status, obese girls, when compared with their average weight counterparts, were 1.63 (95% confidence interval [CI]: 1.16, 2.30) times less likely to hang out with friends in the last week, 1.49 (95% CI: 1.12, 1.98) times more likely to report serious emotional problems in the last year, 1.79 (95% CI: 1.20, 2.65) times more likely to report hopelessness, and 1.73 (95% CI: 1.21, 1.98) times more likely to report a suicide attempt in the last year. Obese girls were also 1.51 (95% CI: 1.09, 2.10) times more likely to report being held back a grade and 2.09 (95% CI: 1.35, 3.24) times more likely to consider themselves poor students compared with average weight girls. Compared with their average weight counterparts, obese boys were 1.91 (95% CI: 1.43, 2.54) times less likely to hang out with friends in the last week, 1.34 (95% CI: 1.06, 1.70) times more likely to feel that their friends do not care about them, 1.38 (95% CI: 1.08, 1.76) times more likely to report having serious problems in the last year, 1.46 (95% CI: 1.05, 0.03) times more likely to consider themselves poor students, and 2.18 (95% CI: 1.45, 3.30) times more likely to expect to quit school. Compared with average weight boys, underweight boys were 1.67 (95% CI: 1.30, 2.13) times more likely to report hanging out with friends in the last week, 1.22 (95% CI: 1.01, 1.49) times more likely to report disliking school, and 1.40 (95% CI: 1.06, 1.86) times more likely to consider themselves poor students.

DISCUSSION

Associations of weight status with social relationships, school experiences, psychological well-being, and some future aspirations were observed. Among girls, the pattern of observations indicates that obese girls reported more adverse social, educational, and psychological correlates. Obese as well as underweight boys also reported some adverse social and educational correlates. These findings contribute to an understanding of how adolescent experiences vary by weight status and suggest social and psychological risks associated with not meeting weight and body shape ideals embedded in the larger culture.

Maternal perceptions of overweight preschool children

CONTEXT

Childhood obesity is a major public health problem, and prevention efforts should begin early in life and involve parents.

OBJECTIVE

To determine what factors are associated with mothers' failure to perceive when their preschool children are overweight.

DESIGN

Cross-sectional survey.

SETTINGS

Offices of private pediatricians and clinics of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

PARTICIPANTS

Six hundred twenty-two mothers with children 23 to 60 months of age.

MAIN OUTCOME MEASURES

Maternal demographic variables, maternal self-reported height and weight, and children's measured height and weight. Mothers were asked whether they considered themselves or their children overweight.

RESULTS

Forty-five percent of mothers had low education (high school degree or less) and 55% had high education (some college or more). Obesity (body mass index: >/=30 kg/m(2)) was more common in the low education group of mothers (30% vs 17%), and their children tended to be more overweight (weight-for-height percentile: >/=90th; 19% vs 14%). Ninety-five percent of obese mothers believed that they were overweight, with no difference between education groups. However, 79% of mothers failed to perceive their overweight child as overweight. Among the 99 mothers with overweight children, low maternal education was associated with a failure to perceive their children as overweight after adjusting for low family income (</=185% of poverty), maternal obesity, age, and smoking plus the child's age, race, and gender (adjusted odds ratio: 6.2; 95% confidence interval: 1.7-22.5).

CONCLUSIONS

Obesity was more common in mothers with less education as well as in their children. Nearly all of the obese mothers regarded themselves as overweight. However, the majority of mothers did not view their overweight children as overweight, and this misperception was more common in mothers with less education. Childhood obesity prevention efforts are unlikely to be successful without a better understanding of how mothers perceive the problem of overweight in their preschool children.

Accuracy of teen and parental reports of obesity and body mass index

OBJECTIVES

Adolescent obesity is becoming an increasing public health problem. This study determines: 1) differences in teen and parental report of obesity, 2) amount of misclassification using body mass index (BMI) from self-reported versus measured height and weight as an indicator of obesity, and 3) whether misclassification varies by gender and socioeconomic status.

DESIGN

Weighted data from 15 483 baseline (T1) youth and parental interviews from the National Longitudinal Study of Adolescent Health were used. Seventy-four percent of teens were reinterviewed 1 year later (T2). Parents reported socioeconomic status indicators and whether their teen was obese. Teens reported height, weight, and weight perception. BMI was calculated from both self-reported height and weight at T1 and T2 and from measured height and weight at T2. Those with a BMI > or =95% corrected for age and gender were considered obese.

RESULTS

At T1, nearly one half of teens (47%) reporting they were very overweight were not obese by BMI. For teens obese by BMI, 19.6% were reported to be obese by both parent and teen, 6.4% by teen only, 29. 9% by parent only, and 44.2% by neither teen nor parent. For those with persistent obesity, teen and/or parental report failed to identify more than one third (34%) as obese; 23.4% were identified by both teen and parent report, 5.4% by teen report only, and 37.2% by parent only. At T2, the correlation between BMI calculated from self-reported versus measured height and weight for the overall population was very strong (r = .92). Specificity of obesity status based on self-reported BMI, compared with obesity status based on measured BMI was .996; sensitivity, .722; positive predictive value, .860; and negative predictive value, .978. Overall, 3.8% of teens were misclassified using self-report measures. Girls were no more likely than boys to be misclassified as obese using BMI from self-reported height and weight.

CONCLUSIONS

Parental report is a better indicator of obesity than teen report of weight status, but parental and teen reports are both poor predictors of adolescent obesity. Using BMI based on self-reported height and weight correctly classified 96% as to obesity status. Thus, studies can use self-reported height and weight to understand teen obesity and its correlates/sequelae.

Psychosocial differences associated with body weight among female adolescents: the importance of body image

PURPOSE

To determine whether overweight female adolescents differ from normal and underweight female adolescents with respect to a set of psychosocial factors, while controlling for body image.

METHODS

Female participants of the National Longitudinal Study of Adolescent Health (n = 3197) were selected for analysis. Multivariate Analysis of Variance (MANOVA) was used to test whether overweight subjects differed from normal and underweight subjects with respect to measures of depression, self-esteem, trouble in school, school connectedness, family connectedness, sense of community, autonomy, protective factors, and grades. Stepdown F-tests and discriminant function coefficients provided information regarding the strength of specific factors in contributing to overall differences.

RESULTS

MANOVA revealed significant differences between groups on the combined set of psychosocial factors. Self-esteem defined the difference in a positive direction while grades defined the difference inversely. When controlling for body image, multidimensional group differences were still evident; however, self-esteem was no longer a significant contributing variable.

CONCLUSIONS

While overweight female adolescents seem to suffer from low self-esteem, it may be explained by body image. Efforts should be directed toward encouraging and supporting healthy eating patterns and physical activity while encouraging students to recognize personal strengths not related to physique.

Nutritional and other influences in childhood as predictors of adult obesity

It has been proposed that there are critical periods during childhood that influence the development of obesity, including gestation and early infancy, the period of adiposity rebound that occurs between ages 5 and 7 years, and adolescence. Despite an extensive literature, there is to date only modest evidence for most of the factors such as nutrition, physical activity and other behavioural factors that are suspected as playing a role in the development of obesity. A recent review of this evidence (Parsons et al. 1999) showed, however, a consistent relationship between socio-economic status (SES) of origin and adult obesity, whereby those from lower SES backgrounds were fatter subsequently in adulthood. This association appeared to apply to both men and women, a finding that contrasts with the trends observed in cross-sectional studies, of an association with SES for women only. There are several potential explanations for the SES of origin-adult obesity relationship. SES of origin may be confounded by parental body size; studies to date provide insufficient evidence of an independent association with SES after allowing for parental body size. Alternatively, environment in early life (for which SES of origin is a proxy measure) may have a long-term impact on obesity later in adulthood, through one or more of several processes. Three major potential explanations can be identified: (1) nutrition in infancy and childhood, either over- or undenutrition, followed subsequently by overnutrition; (2) psychological factors, possibly involving emotional deprivation in childhood; (3) cultural or social norms regarding dietary restraint and attitudes to fatness that may be acquired during childhood.

Weight-related attitudes and behaviors in fourth grade American Indian children

OBJECTIVE

American Indian children have a high prevalence of obesity, yet little is known about weight-related attitudes and the prevalence of dieting in this population. This study assessed weight concerns, body size perceptions, weight reduction attempts, and weight loss methods in fourth grade American Indian children.

RESEARCH METHODS AND PROCEDURES

Participants (n = 304) attended one of eight schools in the Pathways Feasibility Study. Question and answer choices were read to children by trained staff, and children marked their own answers.

RESULTS

Thirty-eight percent of the children reported that they had tried to lose weight. The most common strategy for weight reduction was exercising more. Girls were more likely than boys to be dissatisfied with their body size (48% of girls vs. 34% of boys desired a slimmer body size; 22% of girls vs. 15% of boys desired a larger body size; p<0.001). Children who had tried to lose weight were more likely to indicate that the size they most desired and the most healthy size were smaller than their perceived size (p<0.001). Children who reported trying to lose weight were also more likely to want to be skinnier and to be unhappy about their weight than were children who did not report trying to lose weight (p<0.001 for both).

DISCUSSION

We conclude that weight loss attempts and weight-related concerns are prevalent in American Indian children at a young age.

Self-esteem and adiposity in black and white girls: the NHLBI Growth and Health Study

PURPOSE

Obesity is assumed to have a negative impact on self-esteem because of the associated social stigmatization in Western society. Studies of the psychological effect of obesity in children are inconclusive and limited, particularly pertaining to minority populations. Most studies have assessed global rather than domain-specific measures of self-esteem and hence, may have lacked specificity to detect impairment of certain aspects of self-esteem most closely associated with obesity. The purpose of this study is to examine the effect of adiposity and other environmental factors on measures of perceived competence and self-adequacy in 2205 black and white girls aged 9-10 years.

METHODS

Domain-specific measures of self-esteem were studied by race and degree of adiposity, using Harter's "Self-Perception Profile for Children". Three Harter scales deemed more relevant to obesity (social acceptance (SA), physical appearance (PA), and global self-worth (GSW)) were selected for univariate and multivariate linear regression models to examine relationships between self-esteem level and adiposity (measured by the sum of triceps, subscapular, and suprailiac skinfolds (SSF)), race, pubertal maturation, and parental education. The relationship between adiposity and Harter scores was further examined with LOESS curves and also by comparing the mean scores of each quintile of SSF by race, as well as inter-quintile differences within race.

RESULTS

Adiposity in general impacted negatively on the scores of all three selected Harter scales. There was also racial variation in the relationship between the scores and adiposity, with the magnitude of the effect somewhat less in black girls. White girls exhibited a significant inverse relationship between SSF and SA scores while, in striking contrast, there was no variation in scores in black girls across all ranges of adiposity. Although there was a significant inverse relationship between adiposity and PA and GSW in both groups, the slope was steeper in white girls, particularly at higher ranges of SSF. Non-linearity in the relationship between SSF and the scores was seen in SA and PA scales.

CONCLUSIONS

The present study demonstrated a significant negative association between adiposity and the level of self-esteem in girls as young as 9 to 10 years. There were also intriguing racial differences in the selected domains of esteem. These results may help better understand cultural differences regarding the psychological impact of obesity and could be used to formulate appropriate strategies for public health policy.

Psychosocial concerns and weight control behaviors among overweight and nonoverweight Native American adolescents

OBJECTIVE

To compare the psychosocial and weight-related concerns and weight control, eating, and exercise behaviors of overweight and nonoverweight Native American adolescents living on or near reservations.

STUDY DESIGN

A cross-sectional survey assessed psychosocial, health, and weight-specific concerns; disordered eating; and health-promoting behaviors.

STUDY POPULATION

The study population included 11,868 Native American youth in grades 7 through 12.

STATISTICAL ANALYSES PERFORMED

Analyses of variance and chi 2 tests were used to examine associations between weight status and psychosocial and weight-related concerns and behaviors. Stratified analyses were done by gender and by gender and age.

RESULTS

Self-reported weights and heights indicated that 25% of the study population was overweight. Overweight youth were twice as likely to report health concerns as nonoverweight youth. Although a high percentage of nonoverweight youth expressed body- or weight-related concerns and reported engaging in disordered eating behaviors, prevalence rates for these concerns were significantly higher among overweight youth. Overweight youth were also somewhat less likely to engage in health-promoting behaviors. In contrast, differences in global psychosocial concerns were minimal.

APPLICATIONS

Overweight Native American youth were concerned about their weight, but did not appear to have major psychosocial concerns associated with being overweight. Interventions aimed at obesity prevention and overall health promotion are essential, given the high prevalence of obesity and of psychosocial and weight-related concerns and behaviors among the study population as a whole. The challenge is to develop culturally appropriate interventions aimed at the promotion of healthful weight control behaviors that will not lead to negative psychosocial consequences.

Psychosocial concerns and health-compromising behaviors among overweight and nonoverweight adolescents

OBJECTIVE

To compare weight-specific and global psychosocial concerns and health-compromising behaviors among overweight and nonoverweight youth across gender and ethnicity.

METHODS

A cross-sectional school-based survey of 31,122 adolescents in grades 7 to 12. Based on self-reported heights and weights, respondents were categorized as nonoverweight (body mass index (BMI) < 85th percentile), moderately overweight (85th percentile < BMI < 95th percentile), or severely overweight (BMI > 95th percentile).

RESULTS

Global psychosocial concerns, such as emotional well-being, suicidal ideation, future job concerns, and peer concerns, did not differ greatly between nonoverweight, moderately overweight, and severely overweight adolescents. Substance abuse behaviors were equally or less prevalent among the overweight group. Overweight girls were significantly less likely to consume alcohol, whereas overweight boys were at lower risk for marijuana use. In contrast, overweight youth were more likely to perceive their health as only fair or poor and were more likely to express weight-specific concerns and engage in behaviors such as chronic dieting and binge eating than nonoverweight youth. Overweight American Indian girls perceived their physical health more positively than nonoverweight American Indian girls. Strong associations were found between overweight status and chronic dieting among African American boys and girls.

CONCLUSIONS

Nutritional counseling and educational programs need to address the weight-specific concerns and behaviors of overweight adolescents. However, assumptions regarding global psychosocial concerns and health-compromising behaviors among overweight adolescents of different genders and ethnicities should be avoided. These broad issues need to be explored in more depth at both the research and intervention levels.

Pediatric obesity. An overview of etiology and treatment

Pediatric obesity is a chronic and growing problem for which new ideas about the biologic basis of obesity offer hope for effective solutions. Prevalence of pediatric and adult obesity is increasing despite a bewildering array of treatment programs and severe psychosocial and economic costs. The definition of obesity as an increase in fat mass, not just an increase in body weight, has profound influence on the understanding and treatment of obesity. In principle, body weight is determined by a balance between energy expenditure and energy intake, but this observation does not by itself explain obesity. There is surprisingly little evidence that the obese overeat and only some evidence that the obese are more sedentary. Understanding of the biologic basis of obesity has grown rapidly in the last few years, especially with the identification of a novel endocrine pathway involving the adipose tissue secreted hormone leptin and the leptin receptor that is expressed in the hypothalamus. Plasma leptin levels are strongly correlated with body fat mass and are regulated by feeding and fasting, insulin, glucocorticoids, and other factors, consistent with the hypothesis that leptin is involved in body weight regulation and may even be a satiety factor (Fig. 2, Table 1). Leptin injections have been shown to reduce body weight of primates, although human clinical trials will not be reported until summer 1997. So many peptides influencing feeding have been described that one or more may have therapeutic potential (Fig. 2, Table 1). Although the complexity of pathways regulating body weight homeostasis slowed the pace of understanding underlying mechanisms, these complexities now offer many possibilities for novel therapeutic interventions (Fig. 2). Obesity is a major risk factor for insulin resistance and diabetes, hypertension, cancer, gallbladder disease, and atherosclerosis. In particular, adults who were obese as children have increased mortality independent of adult weight. Thus, prevention programs for children and adolescents will have long-term benefits. Treatment programs focus on modification of energy intake and expenditure through decreased calorie intake and exercise programs. Behavior-modification programs have been developed to increase effectiveness of these intake and exercise programs. These programs can produce short-term weight loss. Long-term losses are more modest but achieved more successfully in children than in adults. Several drug therapies for obesity treatment recently have been approved for adults that produce sustained 5% to 10% weight losses but experience with their use in children is limited. Identification of the biochemical pathways causing obesity by genetic approaches could provide the theoretic foundation for novel, safe, and effective obesity treatments. The cloning of leptin in 1994 has already led to testing the efficacy of leptin in clinical trials that are now underway. Although novel treatments of obesity are being developed as a result of the new biology of obesity, prevention of obesity remains an important goal.

Self-esteem and change in body mass index over 3 years in a cohort of adolescents

Self-esteem has been hypothesized to be lower in obese adolescents relative to their normal weight peers and to be an important factor in preventing or reversing obesity. The present study examined the relationship between obesity and self-esteem cross-sectionally and prospectively over three years in a cohort of 1278 adolescents in grades 7 to 9 at baseline. Cross-sectional analyses revealed an inverse association between physical appearance self-esteem and body mass index in both males and females. In females, body mass index was inversely associated with global self-esteem, close friendship, and behavioral conduct self-esteem. In males, body mass index was inversely associated with athletic and romantic appeal self-esteem. Prospectively, in females, physical appearance and social acceptance self-esteem at baseline were inversely related to body mass index three years later. Baseline self-esteem was unrelated prospectively to change in body mass index in males. All associations were modest in magnitude. These results suggest that in a middle class white sample of adolescents, self-esteem specific to physical appearance is modestly associated with body mass index. Low self-esteem does not appear to predict the development of obesity over time.