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Mansoura Medical Journal (2003); 34 (1&2): 45-49
Body weight and its association with psychosocial health in secondary school female students: the importance of body satisfaction. Mohamed A. Khafagy and Abdel-Halim H. Khalil Community Medicine Department, Faculty of Medicine, Mansoura University. Khafagy MA, Khalil A Mansoura Medical Journal (2003); 34 (1&2): 45-49
Abstract This study was carried out in Mansoura city during the scholastic year 2001-2002. It included 552 secondary school female students to determine the association between body weight and psychosocial health using a set of psychosocial indicators namely; depression, self-esteem, trouble in school, school connectedness, family connectedness, sense of community, autonomy, protective factors, and grades. Among the studied subjects 9.6% were underweight, 59.4% were average weight, 25.7% were overweight, and 5.3% were obese. However, as regards body image, more females (15.9%) considered themselves underweight, and less females (19.8%) considered themselves overweight. In addition, 58.5% of overweight, and 13.8% of obese considered themselves having acceptable body weight. About one third of the studied females (33.2%) were dissatisfied with their bodies, 60.1% of them because of their body configuration. Except for grades, underweight females had the lowest scores for the psychosocial indicators followed by obese and overweight females, while average weight females had the highest scores. Before controlling for body satisfaction, depression, self-esteem, protective factors, trouble in school, and school connectedness were all significant, with self-esteem and depression had the strongest contribution. However, after controlling for body satisfaction, all these indicators became not significant, and the contribution of self-esteem and depression became much lower. In conclusion, this study shows the importance of body satisfaction on self-esteem and depression among adolescent females with the possibility that both underweight and overweight adolescent females may suffer socially and psychologically. Steps should be taken to address these issues within the school health curriculum Healthy body weight should be the ultimate goal and efforts should be directed toward encouraging and supporting healthy eating patterns and physical activity, while encouraging students to recognize that personal strength is not related to physical appearance.
Introduction Throughout most of human history, increased weight and girth of females have been viewed as a sign of health and prosperity. This is still the case in many cultures where some traditional communities have “fattening
1
Mansoura Medical Journal (2003); 34 (1&2): 45-49 huts” for elite pubescent girls to ensure that they a peripheral far energy surplus (Brown and Bentley-Condit, 1998 and WHO, 2000). However, in many industrialized countries, the past three decades have witnessed a marked change in attitudes toward body shape and weight. Thinness in women has come to symbolize competence, success and attractiveness (WHO, 2000). Adolescence is associated with physical, psychological, and emotional changes. Boys typically experience positive feelings toward their changing bodies because of the increase in muscle mass which may be socially beneficial (Frisch, 1983). Girls, may become more dissatisfied with their bodies following puberty because of increased body fat which conflicts in western communities with the cultural ideal of a slender body. Therefore, these physical changes may be a trigger for body dissatisfaction and body image problems with a negative impact on the self-esteem and well-being of the female adolescent (Koff et al., 1990). Body image is the selfperception of body weight and shape, i.e., how a female feels about her body (Gortmake et al., 1993). While, self-esteem consists of two components; how a female believes she is perceived by others and how she views her performance in important areas (Harter, 1990). Recent research suggests that many traditional cultures embrace such values and ideas, and are likely to see an increase in eating disorders and unhealthy weight-control practices (WHO, 2000). The aim of this study was to determine the association of body weight and satisfaction with a set of psychosocial factors in secondary school adolescent females.
Subject and Methods This study was carried out in Mansoura city during the scholastic year 2001-2002. Two secondary schools for females were selected randomly and the consents of the schools’ administrations were obtained. In each selected school, 2 classes were selected randomly from each grade. The total sample included 552 female students. For each student, body weight was recorded to the nearest 0.1 kg using a standard balance beam scale with subject in minimal school uniform and 1 kg was deducted to account for clothing. Body height was recorded to the nearest 0.5 cm with shoes removed using a ruler attached to the scale. Body mass index (BMI) was calculated as the ratio of body weight to squared body height (kg/m2). BMI is a reliable and valid method to determine adiposity both in adult and adolescent populations (Dietz and Robinson, 1998) and tends to correlate with more accurate measures of obesity (Garrow and Webster, 1985). According to WHO classification (WHO, 2000), subjects were classified into underweight (BMI < 18.5 kg/m2), average weight (BMI = 18.5 to 24.99), overweight (BMI= 25.0 to 30), and obese (BMI > 30 kg/m2) A questionnaire was designed to be completed by the students. It covered demographic and socioeconomic items (father’s education and occupation, mother’s education and occupation, family size, number of rooms at home, presence of certain electric appliances). These items were scored and summed to form a socioeconomic score categorized as (low, middle and high). The questionnaire also contained questions about body image (how 2
Mansoura Medical Journal (2003); 34 (1&2): 45-49 does she think of herself, whether underweight, acceptable weight, or overweight) and body satisfaction (her satisfaction with her body weight using 5 grades scale) and the reasons of dissatisfaction if any. The Psychosocial Self-rating Scales (Pesa et al., 2000) were used after modifications to assess psychosocial indicators namely; autonomy (5-items scale, range from 0 to 25), protective factors (4-items scale, range from 0 to 20), family connectedness (4-items scale, range from 0 to 20), school connectedness (5-items scale, range from 0 to 25), trouble at school (4-items scale, range from 0 to 20), sense of community (6-items scale, range from 0 to 30), depression (9-items scale, range from 0 to 45), self-esteem (6-items scale, range from 0 to 18) and grades (5-grades scale, range from 0 to 4 and based on the average of the actual school grades in the last 2 months). For all scales, higher scores are more positive and lower scores are more negative (Pesa et al., 2000). Students were met in the classrooms where they were informed by the investigators that the study is anonymous and that the questionnaire will not be shown to their teachers and parents. This fact was strongly emphasized and the possibility of underreporting was expected to be reduced. Statistical analysis of data was performed using IBM computer and SPSS software. Chi-square test, analysis of variance (ANOVA) and stepwise multivariate analysis of variance (MANOVA) were used as appropriate to assess differences between subgroups. The discriminant function coefficients (DFC) provided additional information on the strength of various factors involved. All reported P-values were 2-tailed and significance was accepted at P< 0.05.
Results Table 1 shows that among the studied subjects 9.6% were underweight (BMI < 18.5 kg/m2), 59.4% were average weight (BMI = 18.5 to 24.99), 25.7% were overweight (BMI = 25.0 to 30), and 5.3% were obese (BMI > 30 kg/m2). The highest prevalence of underweight was among female students aged 15 to less than 16 years (13.6%), while the highest prevalence of overweight and obesity was among female students aged 17 years and more (35.4% and 8.4% respectively). In addition, although there was no significant difference (p > 0.05) between these four subgroups as regards the socioeconomic level, female students belonging to families with high socioeconomic level had higher prevalence of overweight and obesity (28.6% and 6.0% respectively) compared to those belonging to families with low socioeconomic level (22.8% and 4.9% respectively) Table 2 shows body image and satisfaction of the studied subjects. Compared to actual body weight, more females considered themselves underweight (15.9% vs. 9.6%), and less females considered themselves overweight or obese (19.8% vs. 31%). In addition, 58.5% of overweight, and 13.8% of obese considered themselves having acceptable body weight. About one third of the studied females (33.2%) were dissatisfied with their bodies, 60.1% of them because of their body configurations and only 39.9% because of their body weight. The highest prevalence of body dissatisfaction was reported by obese females (72.4%) and underweight females (64.2%). Among overweight females only 39.4% were dissatisfied with their bodies, of them only 30.4% mention and body weight as the reason for their dissatisfaction. 3
Mansoura Medical Journal (2003); 34 (1&2): 45-49 Table 3. Except for grades, underweight subjects had the lowest scores for the other studied psychosocial indicators followed by obese subjects, while average weight subjects had the highest scores for these indicators followed by overweight subjects. Table 4. shows that before controlling for body satisfaction, depression, self-esteem, protective factors, trouble in school, and school connectedness were all significant. However, the discriminant function coefficients (the indicator of the relative strength of each factor) shows that self-esteem and depression had the strongest contribution (DFC = -0.742 and -0.561 respectively), while trouble in school and protective factors were not strong contributors to the overall difference between groups. After controlling for body satisfaction, all the studied psychosocial indicators became not significant, and the contribution of self-esteem and depression to the overall difference between groups became much lower (0.211 and -0.136 respectively).
Discussion In this study both underweight and overweight coexist. Among the studied adolescent females 9.6% were underweight, while 25.7% were overweight, and 5.3% were obese. The highest prevalence of underweight was among females aged 15 to less than 16 years, and the prevalence of overweight and obesity increased with age. In addition, although not significant, students belonging to families with high socioeconomic level had higher prevalence of overweight and obesity compared to those belonging to families with low socioeconomic level. These are consistent with the results of other studies (Khorshid and Galal, 1995; Al-Mannai et al, 1996; AlNuaim, 1997, Delpeuch and Maire, 1997; Steyn et al, 1998; Monteiro et al, 2000). Both underweight and overweight are underlying contributors to two distinct types of public health concerns; overweight is an important determinant of adult- onset diabetes (Lebovitz 1999 ) heart disease and adverse birth outcomes for pregnant women (Cnattingius et al. 1998) whereas underweight has been associated with low bone mass (Ravn et al. 1999 ), and all-cause mortality (Sharp et al. 1998 ). This study points to underestimation of body weight by the studied females. Compared to the actual body weight, more females considered themselves underweight (15.9% vs. 9.6%) and less females considered themselves overweight or obese (19.8% vs. 31%). In addition, 58.5% of overweight, and 13.8% of obese females considered themselves having acceptable body weight. Furthermore, one third of the females reported body dissatisfaction mostly because of their body configurations and not body weight. The highest prevalence of body dissatisfaction was reported by obese females (72.4%) and underweight females (64.2%). It seems that the traditional Egyptian notions of female beauty based on the body feminine features is still prominent and not yet overshadowed by Western pattern of body image, i.e., thinness and slender body. However, in the rapidly urbanizing Egyptian society, the embracement of such Western values and ideas may predispose more females to weight control behavior and eating disorders. In the present study, Except for grades, underweight subjects had the lowest scores for the psychosocial 4
Mansoura Medical Journal (2003); 34 (1&2): 45-49 indicators namely; depression, self-esteem, trouble in school, school connectedness, family connectedness, sense of community, autonomy and protective factors, followed by obese subjects. The average weight subjects had the highest scores for these indicators followed by overweight subjects. Other studies reported that obese girls had more adverse social, psychological and educational correlates compared to underweight girls (Cok, 1990; Falkner et al., 2001; Rozin et al., 2001). Some studies reported association between overweight and depression in adolescent females (Sheslow et al., 1993 and Ross, 1994). Others reported depression and low self-esteem as reasons for weight gain (Cachelin et al., 1998). On the other hand, studies linking body weight with academic performance are inconsistent. Some studies reported that overweight female adolescents do not perform as well academically, compared with their peers (Rhyne-Winkler, 1994 and French et al., 1995). Others reported that overweight subjects outperformed their peers (Pesa et al, 2000). The present study shows a relationship between body satisfaction and both self-esteem and depression. This concept was supported when controlling for body satisfaction cancel the effect of these psychological variables. These findings are consistent with other studies reported that higher levels of body satisfaction among adolescents is associated with lower levels of depression and higher levels of self-esteem (Wadden et al., 1989; Koff et al., 1990; Sheslow et al., 1993 and French et al., 1995), and that negative feelings toward the body may manifest in low self-esteem (Higgins, 1987). In general, body dissatisfaction may be a risk factor for social difficulty and a dissatisfied adolescent female might feel less connected to her family, community, or school. Some studies reported an inverse relationship between the actual body weight and both self-esteem (Fisher et al., 1994 French et al., 1996) and body satisfaction (Kertesz et al., 1992; Adami et al., 1998). However, others reported no relationship (Fowler, 1989; Gortmake et al., 1993; Friedman and Brownell, 1995), suggesting that, in adolescent females, self-esteem is largely dependent upon body satisfaction, rather than the actual body weight (Gortmake et al., 1993; Geller et al., 1997). This self-perception is influenced by the norms, ideals, and values of the community. Therefore, a female who perceives herself as less than ideal will suffer negative feelings toward herself (e.g., low self-esteem or depression). In contrast, a female with positive feelings toward her body, will be less likely to suffer such negative feelings. The present study has some limitations. Being a cross-sectional study, it is impossible to find out whether the association between psychosocial heath and body weight is causal or not. In addition, the findings of the study may not be generalized to include adolescent females in other areas in Egypt, e.g., rural areas and metropolitan cities. In conclusion, this study shows the importance of body satisfaction on self-esteem and depression among adoescent females in Mansoura city with the possibility that both underweight and overweight adolescent females may suffer socially and psychologically. Steps should be taken to address these issues within the school health curriculum. Healthy body weight should be the ultimate goal and efforts should be directed toward 5
Mansoura Medical Journal (2003); 34 (1&2): 45-49 encouraging and supporting healthy eating patterns and physical activity, while encouraging students to recognize that personal strength is not related to physical appearance.
References Adami, G.F., Gandolfo, P., Campostano A., Meneghelli, A., Ravera, G. And Scopinaro, N. (1998): Body image and body weight in obese patients. Int J Eat Disord, 24: 299¯306. Al-Mannai, A., Dickerson, J.W., Morgan J.B. and Khalfan H. (1996): Obesity in Bahraini adults. J. R. Soc. Health, 116: 30-32. Al-Nuaim, A.R. (1997): Prevalence of glucose intolerance in urban and rural communities in Saudi Arabia. Diabetes Med, 14: 595-602. Brown, P. and Bentley-Condit, V.K. (1998): Culture, evolution and obesity. In: Bray, G.A., Bouchard, C. and James, W.P.T. eds. Handbook of obesity. New York, Marcel DeKker, pp. 143-155. Cachelin, F.M., Striegel-Moore, R.H. and Brownell, K.D. (1998): Beliefs about weight gain and attitudes toward relapse in a sample of women and men with obesity. Obes Res, 6: 231¯237. Cnattingius, S., Bergstrom, R., Lipworth, L. and Kramer, M.S. (1998): Prepregnancy weight and the risk of adverse pregnancy outcomes. N. Engl. J. Med., 338: 147-152. Cok, F. (1990): Body image satisfaction in Turkish adolescents.. Adolescence, 25 (98): 409-413 Delpeuch, F., and Maire B. (1997): Obesity and developing countries of the south. Med. Trop., 57: 380-388. Dietz, W.H. and Robinson, T.N. (1998): Use of the body mass index (BMI) as a measure of overweight in children and adolescents. J Pediatr, 132: 191¯193. Falkner N.H., Dianne Neumark-Sztainer, D., Story, M., Jeffery R.W., Beuhring, T. and Resnick, M.D. (2001): Social, Educational, and Psychological Correlates of Weight Status in Adolescents. Obesity Research, 9: 32-42 Fisher, M., Pastore, D., Schneider M., Pegler, C. And Napolitano, B. (1994): Eating attitudes in urban and suburban adolescents. Int J Eat Disord., 16: 67¯74. French, S.A., Perry, C.L., Leon, G.R. and Fulkerson, J.A. (1996): Self-esteem and change in body mass index over 3 years in a cohort of adolescents. Obes Res., 4: 27¯33. French, S.A., Story, M. and Perry, C.L. (1995): Self-esteem and obesity in children and adolescents: literature review. Obes Res., 3: 479¯490. Friedman, M.A. and Brownell, K.D. (1995): Psychological correlates of obesity: moving to the next research generation. Psych Bull, 117: 3¯20. Frisch, R. (1983): Fatness, puberty, and fertility: The effects of nutrition and physical training on menarche and ovulation, in: Girls at Puberty: Biological and Psychosocial Perspectives. Edited by Brooks-
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Mansoura Medical Journal (2003); 34 (1&2): 45-49 Gunn, J. and Petersen A.C., Plenum, New York, pp. 29¯49. Fowler, B.A. (1989): Relationship of body image perception and weight status to recent change in weight status of the adolescent female. Adolescence, 24: 557¯568. Garrow, J.W. and Webster, J. (1985): Quetlet's index as a measure of fatness. Int J Obes, 9: 147¯153. Geller, J., Johnston, C. and Madsen, K. (1997): A new measure of the role of shape and weight in selfconcept: The Shape and Weight Based Self-esteem Inventory. Cog Ther Res, 21: 5¯24. Gortmaker, S.L., Must, A., Perrin, J.M., Sobol, A.M. and Dietz, W.H. (1993): Social and economic consequences of overweight in adolescence and younadulthood. N Engl J Med, 329: 1008¯1012. Harter, S. (1990): Self and identity development, in: At the Threshold: The Developing Adolescent. Edited by Feldman, S. and Elliot, G., Harvard University Press, Cambridge, MA pp. 352¯387. Higgins, E.T. (1987): Self-discrepancy: a theory relating self and affect. Psychol Rev, 94: 319¯340. Kertesz, M., Pollak Z. and Greiner, E. (1992): Evaluation of self-image of overweight teenagers living in Budapest. J Adolesc Health, 13: 396¯397. Khorshid A. and Galal, O.M. (1995): Development of food consumption monitoring system in Egypt. National Agricultural Research Project. Final Report. US Department of Agriculture and the Egyptian Ministry of Agriculture. Koff, E., Rierdan, J. and Stubbs, M.L. (1990): Gender, body image, and self-concept in early adolescence. J Early Adolesc 10: 56¯58. Lebovitz, H.E. (1999): Type 2 diabetes: an overview. Clin. Chem., 45: 1339-1345. Monteiro C.A., Benicio, M.H., Conde, W.L. and Popkin, B.M. (2000): Shifting obesity trends in Brazil. Eur. J. Clin. Nutr., 54: 342-346. Pesa, J.A., Syre, T.R. and Jones, E. (2000): Psychosocial differences associated with body weight among female adolescents: The importance of body image. J Adolescent Health, 26: 330-337. Ravn, P., Cizza, G., Bjarnason, N.H., Thompson, D., Daley, M., Wasnich, R.D., McClung, M., Hosking, D., Yates, A.J. and Christiansen, C. (1999): Low body mass index is an important risk factor for low bone mass and increased bone loss in early postmenopausal women: Early Postmenopausal Intervention Cohort (EPIC) study group. J. Bone Miner. Res., 14: 1622-1627 Rhyne-Winkler, M.C. (1994): Eating attitudes in fourth-, sixth-, and eighth-grade girls. Elem Sch Guidance Counseling, 28: 285¯294. Ross, C.E. (1994): Overweight and depression. J Health Soc Behav, 35: 63¯79. Rozin, P., Trachtenberg, S. and Cohen, A.B. (2001): Stability of body image and body image dissatisfaction in American college students over about the last 15 years. Appetite, 37 (3): 245-248. Sharp, D.S., Masaki, K., Burchfiel, C.M., Yano, K. and Schatz, I.J. (1998): Prolonged QTC interval, impaired pulmonary function, and a very lean body mass jointly predict all-cause mortality in elderly men. 7
Mansoura Medical Journal (2003); 34 (1&2): 45-49 Ann. Epidemiol., 8: 99-106 Sheslow, D., Hassink, S., Wallace, W. And De Lancey E. (1993): The relationship between self-esteem and depression in obese children. Ann NY Acad Sci, 699: 289¯291. Steyn, K., Bourne, L., Jooste, P., Fourie, J.M., Rossouw, K. and Lombard C. (1998): Anthropometric profile of a black population of the Cape Peninsula in South Africa. East Afr. Med. J., 75: 35-40. Wadden, T.A., Foster, G.D., Stunkard, A.J. and Linowitz, J.R. (1989): Dissatisfaction with weight and figure in obese girls: discontent but not depression. Int J Obes, 13: 89¯97. WHO (2000): Understanding how overweight and obesity develop. In: Obesity; preventing and managing the global epidemic. WHO Tchenical Report Series No. 894. WHO, Geneva, pp. 101-152.
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Mansoura Medical Journal (2003); 34 (1&2): 45-49 Table 1. Actual body weight of the studied subjects according to age and socioeconomic level. Age and Actual body weight socioeconomic level
Total
Total
Underweight
Average
Overweight
Obese
No.
%
No.
%
No.
%
No.
%
No.
%
552
100.0
53
9.6
328
59.4
142
25.7
29
5.3
2
Age (years) 15-
191
34.6
26
13.6
125
65.4
36
18.9
4
2.1
16-
183
33.2
15
8.2
115
62.8
43
23.5
10
5.5
17 and more
178
32.2
12
6.7
88
49.4
63
35.4
15
8.4
high
133
24.1
12
9.0
75
56.4
38
28.6
8
6.0
middle
257
46.6
24
9.3
153
59.5
67
26.1
13
5.1
low
162
29.3
17
10.5
100
61.7
37
22.8
8
4.9
26.99 **
Socioeconomic level
ns not significant, p > 0.05,
**
significant, p < 0.001
Table 2. Body image and satisfaction of the studied subjects according to actual body weight. Body image Actual body weight and satisfaction Total Underweight Average Overweight Obese No. % No. % No. % No. % No. % Total
1.70, ns
552
100.0 53
9.6
328
59.4
142
25.7
29
Underweight
88
15.9
36
61.9
46
14.0
6
4.2
0
0.0
Acceptable
355
64.3
17
32.1
251
76.5
83
58.5
4
13.8
Overweight
109
19.8
0
0.0
31
9.5
53
37.3
25
86.2
Satisfied
369
66.8
19
35.8
256
78.0
86
60.6
8
27.6
Dissatisfied
183
33.2
34
64.2
72
22.0
56
39.4
21
72.4
110
60.1
13
38.2
50
69.4
39
69.6
8
38.1
73
39.9
21
61.8
22
30.6
17
30.4
13
61.9
2
5.3
Body image 251.04 ***
Body satisfaction 64.25 ***
Cause of dissatisfation body configuration body weight **
15.77 **
Significant, p < 0.01; *** significant, p < 0.0001
9
Mansoura Medical Journal (2003); 34 (1&2): 45-49 Table 3. Psychosocial indicators among the studied subjects according to actual body weight. Actual body weight Psychosocial indicators Underweight Average Overweight Obesity (Total score) (N=53) (N=328) (N=142) (N=29) F-value mean SD mean SD mean SD mean SD Depression (45) 30.3 5.4 38.2 6.1 37.4 6.0 32.6 4.9 32.28 *** Self-esteem (30)
19.6
5.8
24.3
4.9
23.1
5.2
20.5
4.3
16.86 ***
Protective factors (20)
14.2
2.9
18.4
2.4
17.8
2.7
15.4
3.0
48.94 ***
Autonomy (25)
14.3
2.6
18.1
3.0
18.0
3.2
16.2
2.9
27.13 ***
Family connectedness (20)
13.3
3.5
17.1
3.6
16.6
3.8
14.7
3.2
19.19 ***
Trouble in school (20)
14.1
2.3
16.4
2.8
16.1
2.7
14.6
2.2
13.79 ***
School connectedness (25)
15.2
3.4
19.2
3.8
18.5
3.5
16.1
3.1
22.57 ***
Sense of community (30)
20.8
5.1
25.4
4.3
24.6
4.0
21.9
4.8
38.60 ***
3.6
0.7
3.7
0.8
3.6
0.7
3.5
0.6
1.13 ns
Grades (5)
ns not significant, p > 0.05, *** significant, p < 0.0001
Table 4. The results of stepdown multivariate analysis of variance (MANOVA) Psychosocial indicators Body satisfaction is not controlled Body satisfaction is controlled F DFC F DFC Depression 24.91 ** -0.561 2.89, ns -0.136 Self-esteem
26.22 **
-0.742
2.21, ns
-0.211
Protective factors
4.27 *
-0.046
2.11, ns
-0.163
Autonomy
0.86, ns
-0.052
0.42, ns
-0.011
Family connectedness
1.42, ns
-0.217
0.37, ns
-0.116
Trouble in school
4.61 *
-0.148
0.78, ns
-0.254
School connectedness
4.81 *
-0.088
1.31, ns
-0.043
Sense of community
1.89, ns
-0.021
0.66, ns
-0.008
Grades
0.47, ns
-0.001
1.64, ns
-0.102
N.B. variables included age, grade and socioeconomic level. DFC = discriminant function coefficient. ns not significant, p > 0.05; * significant, p < 0.05; ** significant, p < 0.001
10
