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Weight-Related Concerns and Behaviors Among Overweight and Nonoverweight Adolescents
Implications for Preventing Weight-Related Disorders
Dianne Neumark-Sztainer, PhD, MPH, RD;
Mary Story, PhD;
Peter J. Hannan, MStat;
Cheryl L. Perry, PhD;
Lori M. Irving, PhD
Arch Pediatr Adolesc Med. 2002;156:171-178.
ABSTRACT
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Objectives To assess weight-related concerns and behaviors in a population-based
sample of adolescents and to compare these concerns and behaviors across sex
and weight status.
Design The study population included 4746 adolescents from St Paul or Minneapolis,
Minn, public schools who completed surveys and anthropometric measurements
as part of Project EAT (Eating Among Teens), a population-based study focusing
on eating patterns and weight concerns among teenagers.
Main Outcome Measures Measured weight status, weight-related concerns (perceived weight status,
weight disparity, body satisfaction, and care about controlling weight), and
weight-related behaviors (general and specific weight control behaviors and
binge eating).
Results Weight-related concerns and behaviors were prevalent among the study
population. Although adolescents were most likely to report healthy weight
control behaviors (adolescent girls, 85%; and adolescent boys, 70%), also
prevalent were weight control behaviors considered to be unhealthy (adolescent
girls, 57%; and adolescent boys, 33%) or extreme (adolescent girls, 12%; and
adolescent boys, 5%). Most overweight youth perceived themselves as overweight
and reported the use of healthy weight control behaviors during the past year.
However, the use of unhealthy and extreme weight control behaviors and binge
eating were alarmingly high among overweight youth, particularly adolescent
girls. Extreme weight control practices (taking diet pills, laxatives, or
diuretics or vomiting) were reported by 18% of very overweight adolescent
girls, compared with 6% of very overweight adolescent boys (body mass index,  95th
percentile).
Conclusion Prevention interventions that address the broad spectrum of weight-related
disorders, enhance skill development for behavioral change, and provide support
for dealing with potentially harmful social norms are warranted in light of
the high prevalence and co-occurrence of obesity and unhealthy weight-related
behaviors.
INTRODUCTION
OBESITY AMONG children and adolescents has reached epidemic proportions
in the United States. One of the Healthy People 2010 objectives is to "reduce
the proportion of children and adolescents who are overweight or obese."1(chap 19, p13) The aim is to decrease the percentage
of youth (aged 6-19 years) with body mass index (BMI) values above the 95th
percentile from 11% to 5%.1 However, there
is no evidence that the prevalence of obesity is decreasing; rather, data2-3 suggest a continuing upward trend.
The high prevalence of obesity among youth and its potentially serious psychosocial
and physical consequences4 have made obesity
one of the greatest contemporary public health issues. Numerous questions
exist regarding effective strategies for preventing and treating obesity among
youth.5-11
Another public health concern related to eating and weight is the high
prevalence of body dissatisfaction, unhealthy weight control behaviors, and
other disordered eating patterns, particularly among adolescent girls.12-18
Excessive weight-related concerns and behaviors have potentially serious consequences
for youth in their impact on psychosocial development, dietary intake, physical
growth, and the development of eating disorders.19-25
It could be argued that we need not be concerned about weight-related concerns
and behaviors in light of more pressing concerns regarding obesity. However,
there is reason for concern if nonoverweight youth are attempting weight loss
and if unhealthy weight control behaviors are being used by youth, regardless
of their weight status. As with obesity prevention, questions exist regarding
the most effective strategies for preventing excessive weight concerns and
unhealthy weight control/disordered eating behaviors.26-29
To date, the fields of obesity prevention and dieting/eating disorder
prevention have been quite separate. However, it could be argued that it is
possible, and practical, to view these issues as overlapping and to work toward
developing integrative interventions that address the broad range of weight-related
disorders. To develop effective interventions aimed at preventing obesity
and unhealthy dieting/disordered eating, a greater understanding of the types
of weight-related concerns and behaviors among youth is needed. In developing
interventions for obesity prevention, it is particularly important to be cognizant
of the specific weight-related concerns and behaviors among overweight youth.
The present study was designed to (1) examine specific weight-related
concerns and behaviors in a large population-based sample of adolescent girls
and boys; (2) compare weight-related concerns and behaviors among underweight,
nonoverweight, moderately overweight, and very overweight adolescents; and
(3) explore the overlap between overweight status and unhealthy weight-related
behaviors and consider implications for interventions.
PARTICIPANTS AND METHODS
STUDY POPULATION AND STUDY DESIGN
The overall study population consists of 4746 adolescents from 31 public
middle schools and high schools from urban and suburban school districts in
the St Paul and Minneapolis, Minn, area. The mean age of the study population
was 14.9 years (SD, 1.7 years); 34% were in junior high school and 66% were
in high school. The racial/ethnic background of the participants was as follows:
48% white, 19% African American, 19% Asian American, 6% Hispanic, 4% Native
American, and 4% mixed or other. Participants were equally divided by sex.
Data for the present study were drawn from Project EAT (Eating Among
Teens), a comprehensive study of adolescent nutrition and obesity. Trained
research staff administered surveys within school classes and assessed height
and weight within a private area. Study procedures were approved by the University
of Minnesota Human Subjects' Committee and by the research boards of the participating
school districts. Consent procedures were done in accordance with the requests
of the participating school districts; in some schools, passive consent procedures
were used, while in others, active consent procedures were required. The response
rate for student participation was 81.5%; the main reasons for lack of participation
were absenteeism and failure to return consent forms within schools requiring
active consent.
SURVEY DEVELOPMENT
The Project EAT survey is a 221-item self-report instrument assessing
a range of factors of potential relevance to nutritional health and obesity
among adolescents. The development of the survey was guided by focus group
discussions with youth,30 a theoretical framework
(Social Cognitive Theory) for understanding factors influencing eating behavior,31-32 a review of the literature for existing
instruments,33-38
numerous reviews by professionals from different disciplines and adolescents
with different backgrounds, and several pilot tests of the survey.
MEASURES
Weight status was based on height and weight measurements taken by trained
research staff using standardized equipment and procedures. Body mass index
values were calculated according to the following formula: weight in kilograms
divided by the square of height in meters. Sex- and age-specific cutoff points
were based on reference data from the Centers for Disease Control and Prevention
growth charts.39-40 For this study,
respondents were classified as underweight (BMI, <15th percentile), average
weight (BMI, 15th-<85th percentile), moderately overweight (BMI, 85th-<95th
percentile), and very overweight (BMI, 95th percentile). Among the adolescent
girls, the mean BMI values were 16.6, 20.9, 26.0, and 32.9 for the underweight,
average-weight, moderately overweight, and very overweight categories, respectively.
Among the adolescent boys, the mean corresponding BMI values were 17.0, 20.9,
25.1, and 31.6.
Weight-related concerns assessed included the following: perceived weight
status, weight disparity, body satisfaction, and care about controlling weight.
Perceived weight status was assessed with the following question: "At this
time do you feel that you are . . . (1) very underweight, (2) somewhat underweight,
(3) about the right weight, (4) somewhat overweight, or (5) very overweight?"
Weight disparity was based on 2 questions ("How much do you weigh?" and "At
what weight do you think you would look best?") and was calculated as desired
weight as a percentage of reported weight. Responses of less than 100% indicate
that one's desired weight was lower than one's reported weight, while responses
greater than 100% indicate that one's desired weight was higher than one's
reported weight. Body satisfaction was assessed with a modified version of
the Body Shape Satisfaction Scale,35 which
included 10 items assessing satisfaction with different body parts (eg, height,
weight, stomach, and hips), with 5 Likert response categories ranging from
"very dissatisfied" to "very satisfied" (Cronbach  = .92). Responses
were categorized as low, moderate, and high based on distributions within
the study population, with one third of the population in each category. Care
about controlling weight was assessed with the following question: "How much
do you care about controlling your weight . . . (1) not at all, (2) a little
bit, (3) somewhat, or (4) very much?"
Several weight-related behaviors were assessed in this study. Currently
trying to lose weight was assessed with the following question: "Are you currently
trying to . . . (1) lose weight, (2) stay the same weight, (3) gain weight,
or (4) I am not trying to do anything about my weight?" Trying to lose or
maintain weight during the past year was assessed with the following question:
"During the past year, have you done anything to try to lose weight or keep
from gaining weight?" Long-term dieting (5 times per year) was assessed
with the following question: "How often have you gone on a diet during the
last year? By ‘diet,' we mean changing the way you eat so you can lose
weight . . . (1) never, (2) 1 to 4 times, (3) 5 to 10 times, (4) more than
10 times, or (5) I am always dieting." Extreme weight control practices during
the past week were assessed with the following question: "During the past
week, did you do any of the following to lose weight or keep from gaining
weight . . . (1) made myself vomit (throw up), (2) took diet pills, or (3)
used laxatives?" Respondents using any of these methods were categorized as
using extreme methods in the past week. Respondents were also asked if they
had ever been told they had an eating disorder by a health professional: "Has
a doctor ever told you that you have an eating disorder such as anorexia nervosa,
bulimia nervosa, or binge-eating disorder? (yes or no)." Binge eating was
assessed with the following question: "In the past year, have you ever eaten
so much food in a short period of time that you would be embarrassed if others
saw you (binge eating)? (yes or no)." Healthy, unhealthy, and extreme weight
control behaviors during the past year were assessed with the following question:
"Have you done any of the following things in order to lose weight or keep
from gaining weight during the past year? (yes or no for each method)." Responses
classified as healthy weight control behaviors included (1) exercised, (2)
ate more fruits and vegetables, (3) ate less high-fat foods, and (4) ate less
sweets. Responses classified as unhealthy weight control behaviors included
(1) fasted, (2) ate very little food, (3) used a food substitute (powder or
a special drink), (4) skipped meals, and (5) smoked more cigarettes. Responses
classified as extreme weight control behaviors included (1) took diet pills,
(2) made myself vomit, (3) used laxatives, and (4) used diuretics.
Sex, school level, ethnicity/race, and socioeconomic status were based
on self-report. The prime determinant of socioeconomic status was parental
educational level, defined by the higher level of educational attainment of
either parent. Other variables taken into account in assessing family socioeconomic
status included family eligibility for public assistance, eligibility for
free or reduced-cost school meals, and employment status of the mother and
father.
DATA ANALYSIS
Percentages of youth reporting weight-related concerns and behaviors
were examined across sex and weight status among adolescent girls and boys
separately.  2 Values were calculated by analysis-of-variance
models that included the school as a random component of variance. Selected
outcome variables were dichotomized to investigate, separately by sex, the
associations with weight status, adjusted for sociodemographic characteristics.
Logistic regression models, which included the school as a random effect and
the average-weight group as a reference group, were used to generate adjusted
odds ratios and 95% confidence intervals for weight status. Odds ratios are
statistically significant (P<.05) when 1.0 is
not included in the 95% confidence interval. All analyses were carried out
using SAS statistical software, release 8.0.41
RESULTS
SEX COMPARISONS OF WEIGHT STATUS AND WEIGHT-RELATED CONCERNS AND BEHAVIORS
There were modest, albeit statistically significant (P<.001), differences in weight status across sex. Among adolescent
girls, 4.6% were underweight, 62.8% were average weight, 20.0% were moderately
overweight, and 12.6% were very overweight. Among adolescent boys, 5.7% were
underweight, 63.1% were average weight, 14.6% were moderately overweight,
and 16.6% were very overweight. In contrast, as seen in Table 1, large differences were noted for nearly all of the weight-related
concerns and behaviors. Adolescent girls expressed greater concerns and were
more likely to report engaging in weight-related behaviors than adolescent
boys; all differences were statistically significant (P<.001), except for ever told had an eating disorder (P = .28), laxative use (P = .02), and diuretic
use (P = .79). Among both sexes, healthy weight control
practices were commonly reported; 85.4% of the adolescent girls and 69.9%
of the adolescent boys reported healthy practices during the past year. However,
56.9% of the adolescent girls and 32.7% of the adolescent boys reported unhealthy
practices and 12.4% of the adolescent girls and 4.6% of the adolescent boys
reported extreme practices (Table 1).
While adolescent girls were more likely than adolescent boys to express weight-related
concerns and to engage in weight-related behaviors, significant numbers of
adolescent boys also reported these concerns and behaviors.
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Table 1. Weight-Related Concerns and Behaviors Among Adolescents by
Sex and Weight Status*
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WEIGHT-RELATED CONCERNS AND BEHAVIORS ACROSS WEIGHT STATUS
Numbers and Percentages
For most adolescent girls, perceived weight status was in accordance
with actual weight status (Table 1).
For example, 81.2% of the very overweight adolescent girls and 68.3% of the
moderately overweight adolescent girls perceived themselves as somewhat overweight
or very overweight. However, there were some notable exceptions in which perceived
weight status differed from actual weight status. Weight disparity was strongly
correlated with weight status: high percentages of very overweight adolescent
girls (86.5%) desired to weigh less than 90% of their self-reported weight,
and high percentages of underweight adolescent girls (68.1%) desired to weigh
more than their self-reported weight. Still, a high percentage of the average-weight
adolescent girls (63.8%) desired to weigh less than their self-reported weight.
Body satisfaction was inversely associated with weight status. Caring about
controlling weight (somewhat or very much) was reported by high percentages
of average, moderately overweight, and very overweight adolescent girls; percentages
of underweight adolescent girls who reported caring were considerably lower.
Strong correlations were found between weight status and nearly all of the
weight-related behaviors among the adolescent girls; the highest use was reported
by the very overweight adolescent girls, and the lowest use was reported by
the underweight adolescent girls. Among very overweight adolescent girls,
95.4% reported healthy weight control practices, 76.0% reported unhealthy
practices, and 17.9% reported extreme practices during the past year. Among
adolescent girls, the only differences that were not statistically significant
across weight status were for ever told had an eating disorder (P = .77), vomited (P = .19), and took diuretics
(P = .90). Differences were statistically significant
for binge eating (P = .03), fasted (P = .002), smoked more cigarettes (P = .04),
and took laxatives (P = .02). All other differences
were highly statistically significant (P<.001).
Among the adolescent boys, there were also strong correlations between
weight-related concerns and behaviors and weight status (Table 1), although some of the trends differed from those found
among the adolescent girls. Most very overweight adolescent boys (75.2%) perceived
themselves as somewhat or very overweight, but only 38.3% of the moderately
overweight adolescent boys perceived themselves in this way. Furthermore,
in contrast to the adolescent girls, only a small percentage of the average-weight
adolescent boys perceived themselves as somewhat or very overweight (6.6%),
while 23.9% perceived themselves as underweight. Weight disparity was strongly
associated with weight status among the adolescent boys, as was found among
the adolescent girls. However, in contrast to the adolescent girls, nearly
half (49.2%) of the average-weight adolescent boys indicated that they wanted
to weigh more than their self-reported weight. Body satisfaction was lowest
among the very overweight adolescent boys, followed by the underweight adolescent
boys. This was a different pattern from that found among the adolescent girls
(in that underweight adolescent girls expressed the highest level of body
satisfaction). Caring about controlling weight seemed to be highest among
the moderately and very overweight adolescent boys. For most of the weight-related
behaviors, there were direct associations with weight status; very overweight
adolescent boys were most likely to report their use, followed by moderately
overweight adolescent boys. However, for some of the more extreme weight control
practices, there seemed to be a U-shaped association with weight status, and
their use tended to be highest among very overweight and underweight adolescent
boys. These associations were further explored in multivariate analyses (described
later). Among adolescent boys, all differences across weight status were statistically
significant (P<.01 or P<.001),
except for ever told had an eating disorder (P =
.12), smoked more cigarettes (P = .80), took laxatives
(P = .80), took diuretics (P
= .25), and took diet pills (P = .03).
Adjusted Odds Ratios
Associations between weight-related concerns and behaviors and weight
status were further examined, controlling for school level, race, and socioeconomic
status. Using average-weight youth as the reference group, odds ratios and
95% confidence intervals were calculated for adolescent girls (Table 2) and boys (Table 3).
In general, patterns were similar to those found in the bivariate analyses
previously described. Among adolescent girls and boys, compared with average-weight
youth, overweight youth were more likely to perceive themselves as overweight,
desire to weigh less, and express body dissatisfaction. Similarly, overweight
youth were more likely to engage in weight control practices and binge eating
than average-weight youth. This pattern was apparent between both sexes.
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Table 2. Weight-Related Concerns and Behaviors Among Adolescent Girls
by Weight Status*
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Table 3. Weight-Related Concerns and Behaviors Among Adolescent Boys
by Weight Status*
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Underweight adolescent girls were less likely to report weight-related
concerns and behaviors than average-weight adolescent girls (Table 2). Similarly, underweight adolescent boys were less likely
than average-weight adolescent boys to express several weight-related concerns
(eg, care about controlling weight) and to engage in general weight control
practices (eg, tried to lose or maintain weight in the past year) and healthy
weight control practices (Table 3).
However, compared with average-weight adolescent boys, underweight adolescent
boys were at greater risk for low body satisfaction and extreme weight control
behaviors in the past week.
COMMENT
This study aimed to assess weight-related concerns and behaviors in
a large sample of adolescents and to compare these concerns and behaviors
across sex and weight status. In light of the high and rapidly increasing
prevalence of obesity among youth,1-3
we were particularly interested in examining weight-related concerns and behaviors
among overweight youth to guide the development of appropriate prevention
and treatment interventions.
Adolescents in the study population, particularly girls, reported a
high prevalence of weight-related concerns and behaviors. It was encouraging
that healthy weight control practices (eg, decreasing fat intake) were more
commonly reported than practices considered to be unhealthy (eg, skipping
meals) or extreme (eg, self-induced vomiting). Many of the healthy weight
control behaviors (eg, increasing physical activity), used judiciously, are
recommended for all adolescents, regardless of their weight status.1 There is considerable debate about whether we need
to be concerned about the high prevalence of dieting behaviors among adolescents,
particularly adolescent girls.27 Previous studies12, 33, 42-43 have
included general questions about dieting and/or weight loss attempts, and
youth may define dieting or trying to lose weight differently,44-45
making interpretations from such studies somewhat difficult. The finding that
many youth in the present study reported using specific healthy weight control
behaviors might suggest that we need not be overly concerned with the high
prevalence of self-reported weight control attempts found across studies.
However, in addition to healthy weight control behaviors, many nonoverweight
and overweight youth reported engaging in unhealthy and extreme weight control
behaviors. Furthermore, a high percentage of average-weight girls perceived
themselves as overweight, desired to weigh less, and expressed body dissatisfaction.
These findings suggest that we do need to be concerned about the high prevalence
of dieting among youth, particularly among adolescent girls.
Many of the overweight youth in the present study accurately perceived
themselves as overweight, reported that they cared about controlling their
weight, and had engaged in healthy weight control behaviors during the past
year. These findings suggest that most overweight teenagers are motivated
to achieve a healthier weight and have made some positive steps toward that
goal. This suggests that, for most youth, little time within interventions
needs to be devoted toward identifying who is overweight, discussing the importance
of weight control, and superficially reviewing desirable weight control behaviors.
However, time may need to be devoted to skill development in learning how
to successfully engage in healthy weight control behaviors, such as increasing
physical activity and increasing fruit and vegetable intake, decreasing fat
intake, and decreasing sweets in one's diet. Previous studies1, 46-49
among youth have found high levels of fat intake, low levels of physical activity,
and low levels of fruit and vegetable intake. Therefore, many adolescents
who report the use of these behaviors for weight control purposes may not
be implementing them adequately.
The high prevalence of binge eating and unhealthy or extreme weight
control behaviors exhibited by overweight youth (especially by overweight
girls) demonstrates a need to also address these behaviors within interventions
for overweight youth. Individual factors associated with binge eating should
be identified (eg, excessive dietary restraint), and alternative behaviors
for dealing with triggers to binge eating should be developed. The potential
dangers of unhealthy or extreme weight control behaviors and their ineffectiveness
for long-term weight control should be discussed. Previous studies50-51 have found that body dissatisfaction
is a strong predictor of unhealthy weight control practices, suggesting that
to decrease the use of unhealthy weight control behaviors, it may be important
to develop interventions that simultaneously aim for improved body satisfaction
and the development of realistic weight goals.
While most overweight youth seemed motivated to achieve a healthier
weight through healthy means, this was not always the case. For example, about
one fifth of the very overweight girls and one fourth of the very overweight
boys did not perceive themselves as somewhat or very overweight, suggesting
that they may not be interested in losing weight. This finding supports the
value of assessing readiness for change and developing an appropriate intervention
plan.52 For the few overweight youth who do
not perceive a need for weight control, the focus will need to be on encouraging
an accurate awareness of the individual's weight status and eating and physical
activity habits and on getting the individual to understand the potential
harms of obesity and the benefits of adopting healthy lifestyle behaviors
to prevent unhealthy weight gain. As the adolescent perceives a need to change,
the focus can be shifted toward increasing self-efficacy and skill development
for behavioral change. Family and peer support networks may be necessary for
overweight youth, regardless of the stage of readiness for change in behaviors.
This study had several strengths that enhance our ability to draw conclusions
from the findings. The population-based nature of the sample allows for more
generalization than would be possible from a clinic-based sample of youth.
Another strength was the collection of actual height and weight measurements;
most large population-based studies of youth rely on self-reported height
and weight data33, 53 or do not
even include questions assessing height and weight.54
A major strength of the study was the assessment of various weight-related
concerns and behaviors. Typically, population-based surveys of youth address
a broad range of health-related issues; therefore, questions regarding weight-related
concerns and behaviors have been quite general.33, 53, 55-56
However, questions still remain unanswered regarding the frequency and the
intensity of specific weight control behaviors reported. Furthermore, as in
any study assessing self-reported behaviors, questions of validity arise.
Finally, because of the cross-sectional nature of the study, we can only state
that overweight status was associated with increased unhealthy weight control
behaviors. We cannot determine whether these behaviors led to a higher prevalence
of obesity or whether overweight youth chose to engage in these behaviors
in an attempt to lose weight.
Traditionally, interventions aimed at preventing and treating obesity
focus on increasing physical activity and decreasing calorie (energy) intake.
Interventions aimed at preventing disordered eating/eating disorders tend
to focus more on promoting a positive body image and on dieting prevention.
Recently, there have been discussions about decreasing existing disparities
between the obesity and eating disorder fields. These discussions have arisen
because of an increased recognition of some of the similarities between these
conditions and a need for taking both into account in the development of interventions,
particularly primary prevention interventions. Our findings suggest a need
for identifying and addressing shared predictive factors for obesity and disordered
eating behaviors (ie, unhealthy weight control and binge-eating behaviors),
because for many youth they co-occur. Models examining shared predictive factors
for disordered eating/eating disorders and obesity need to be developed and
tested. Different intervention strategies that address the broad spectrum
of weight-related concerns and behaviors need to be developed, implemented,
and evaluated. For example, within interventions for overweight adolescents,
there is a need to address body image issues and unhealthy dieting behaviors
in addition to focusing on changes in eating and physical activity behaviors.
In interventions aimed at preventing disordered eating/eating disorders, there
may be a need to discuss and provide skills for healthful weight management.
Through the development, evaluation, and refinement of such programs, it may
be possible to decrease the high prevalence of disordered eating and obesity.
| What This Study Adds
Studies suggest that weight-related concerns and behaviors, including
obesity, body dissatisfaction, and healthy and unhealthy weight control behaviors,
are prevalent among adolescents. However, large population-based studies of
youth are limited in their ability to explore interrelations between weight
status and weight-related behaviors because of inadequate assessments of these
variables. In the present study, measured height and weight and a range of
weight-related concerns were assessed in a large and diverse population of
adolescents. The high prevalence of overweight youth reporting weight control
behaviors indicates that most overweight youth are aware that they are overweight,
but may need intensive interventions to provide them with adequate skills
to engage in healthy eating and increased physical activity. The high prevalence
and co-occurrence of obesity and unhealthy weight control behaviors found
in this study suggest that there is a need for interventions that address
the broad spectrum of weight-related disorders.
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AUTHOR INFORMATION
Accepted for publication September 19, 2001.
This study was supported by grant MCJ-270834 from the Maternal and Child
Health Bureau (Title V, Social Security Act), Health Resources and Service
Administration, US Department of Health and Human Services, Rockville, Md
(Dr Neumark-Sztainer).
We thank the students and staff from the St Paul and Osseo, Minn, school
districts for participating in this study.
Corresponding author and reprints: Dianne Neumark-Sztainer, PhD,
MPH, RD, Division of Epidemiology, School of Public Health, University of
Minnesota, 1300 S Second St, Suite 300, Minneapolis, MN 55454.
From the Division of Epidemiology, School of Public Health, University
of Minnesota, Minneapolis (Drs Neumark-Sztainer, Story, and Perry and Mr Hannan);
and the Department of Psychology, Washington State University, Vancouver (Dr
Irving).
Dr Irving is deceased.
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