Association between BMI for Obesity and Distress about Appearance in Korean Adolescents (original) (raw)

  1. Home
  2. Archive
  3. v.33(20); May 2018
  4. 10.3346/jkms.2018.33.e150

© 2018 The Korean Academy of Medical Sciences.

Original Article

Received December 28, 2017; Accepted March 13, 2018.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Previous research has related obesity to body dissatisfaction and low self-esteem. This study aimed to evaluate this relation between obesity and distress about appearance.

Methods

We performed a cross-sectional study using data from the Korea Youth Risk Behavior Web-based Survey for 288,390 participants assessed from 2009 to 2012. The participants were categorized according to body mass index; obese, overweight, healthy weight, and underweight. The relation between obesity and distress was analyzed using simple and multiple logistic regression with complex sampling adjusted for age, sex, region of residence, economic level, parental education level, alcohol consumption, and smoking habits as confounders.

Results

The adjusted odds ratio (AOR) was higher for participants with obesity (AOR for healthy weight = 1.15 [95% confidence interval {CI}, 1.08–1.22]; AOR for overweight = 1.85 [95% CI, 1.72–1.98]; AOR for obese = 2.45 [95% CI, 2.27–2.64]; reference = underweight, P < 0.001). In males, healthy weight was associated with an AOR below 1 (AOR for healthy weight = 0.92 [95% CI, 0.85–0.99]; AOR for overweight = 1.26 [95% CI, 1.14–1.38]; AOR for obese = 1.66 [95% CI, 1.50–1.84], P < 0.001). In females, higher AORs were associated with obesity (AOR for healthy weight = 1.44 [95% CI, 1.33–1.57]; AOR for overweight = 2.71 [95% CI, 2.45–2.99]; AOR for obese = 3.71 [95% CI, 3.32–4.14], P < 0.001).

Conclusion

Obesity is related to distress about appearance, and the relation is stronger in girls than in boys.

Graphical Abstract

Keywords

Obesity; Body, Physical Appearance; Stress, Psychological; Adolescent; Beauty

INTRODUCTION

Body dissatisfaction is influenced by biological, psychological, and sociocultural factors.1 Obesity has been found to be strongly related to body dissatisfaction in previous studies.2, 3, 4, 5, 6 Even in childhood and adolescence, obese persons suffer psychological disturbances based on unfair prejudice and discrimination.7, 8 Negative parental opinions about body weight and teasing by friends are linked to body dissatisfaction in individuals from a young age.4, 9, 10, 11 The result is low self-esteem for obese people,2, 5 and the decreased self-esteem links the relationship between body dissatisfaction and depressed mood.12 Therefore, obese children may experience stress due to their entire appearance, including their face and body shape as well as weight. However, few studies have evaluated whether overweight or even children or adolescents of healthy weight are stressed about their appearance using a large population-based study with representative samples.

In Korea, interest in appearance is unusually high.13 The rate of cosmetic surgery in Korea has been reported to be the highest in the world,14 and appearance-related distress is the second most common cause of distress in Korean adolescents.15 Although the rate of obesity is very low (3.8%) in Korea, the desire to lose weight is greater in Korea than in any other countries, particularly for young women.16 Thus, we hypothesized that Korean adolescents, especially obese girls, might be very distressed about their appearance.

The purpose of this study was to evaluate the relation between obesity and distress about appearance in adolescents using a large population-based sample that was designed to be representative of Korean adolescents. Furthermore, we divided the participants into subgroups to reveal different associations according to age and sex.

METHODS

Study population and data collection

This cross-sectional study uses the data from the Korea Youth Risk Behavior Web-based Survey (KYRBWS). This study based on data from one nation employs statistical methods based on designed sampling and adjusted weighted value. Data from the KYRBWS, conducted from 2009 through 2012, were analyzed. The data were collected by the Korea Centers for Disease Control and Prevention (KCDC). Korean adolescents from 7th through 12th grade completed the self-administered questionnaire voluntarily and anonymously. The validity and reliability of the KYRBWS have been documented in other studies.17, 18 The surveys yielded data from Korean adolescents using stratified, two-stage (schools and classes) clustered sampling based on Ministry of Education data. Sampling was weighted by statisticians, who performed post-stratification and considered the non-response rates and extreme values.

Of the total of 298,133 participants, we excluded the following students from participating in this study: adolescents who did not record their height or weight (9,222 participants) and adolescents who did not indicate the education level of their mother and their drinking alcohol history (2 participants). Finally, 288,909 participants (149,226 males and 139,683 females) from 12 to 18 years old were included in this study (Fig. 1).

Fig. 1
A schematic illustration of participant selection in the present study. Among a total of 298,133 participants, participants with incomplete survey data were excluded from this study. The data for the 288,909 participants with complete data were analyzed.

Survey

The understanding, reliability and validity of each question were investigated by the KCDC in qualifying the surveys.19 The region of residence was divided into 3 groups by administrative district: large city, small city, and rural area. Obesity was categorized into 4 groups according to KCDC guidelines for body mass index (BMI, kg/m2) for children and teens20: obese, ≥ 95th percentile; overweight, 85th–95th percentile; healthy weight, 5th–85th percentile; and underweight, < 5th percentile. Self-reported economic status was measured in 5 levels from the highest to lowest. Parental education level was divided into 4 groups: parents who had graduated from college or higher; parents who had graduated from high school; parents who had graduated middle school or lower; and those with unknown education or no parents. Participants who did not know their parents' educational level or who had no parents were not excluded, as this could have increased the number of missing values for participants with relatively lower economic status. The participants were asked to indicate their academic performance in their grade at school during the last 12 months. Performance at school was divided into 5 levels: A (highest), B (middle, high), C (middle), D (middle, low), and E (lowest). The participants were asked how many days they had smoked cigarettes in the past month, and this information was divided into 3 groups: 0 days per month, 1–19 days per month, and ≥ 20 days per month. The participants were asked how many days they had consumed alcohol based on 3 possibilities: 0 days per month, 1–5 days per month, and 6–30 days per month.

The participants were asked to indicate their most serious source of stress among conflict with parents, conflict with teachers, peer relationship, academic issue, health problem, family economic situation and appearance (height, body shape, or looks). The participants who chose appearance were classified as being distressed about their appearance.

Statistical analysis

Differences in general characteristics according to obesity status were calculated using linear regression analysis with complex sampling and a χ2 test with Rao-Scott correction.

Odd ratios (ORs) for obesity associated with distress about appearance were calculated using simple and multiple logistic regression analysis with complex sampling.

For the subgroup analysis according to the age and sex (boy vs. girl; younger [12–14 years of age] vs. older [15–18 years of age]), the adjusted odds ratios (AORs) for obesity in relation to distress about appearance were calculated using multiple logistic regression analysis with complex sampling.

Two-tailed analyses were conducted, and P values lower than 0.05 were considered to indicate significance. A 95% confidence interval (CI) was calculated. After the weighted values recommended by the KYRBWS were applied, all results were presented as weighted values. The results were analyzed statistically using SPSS ver. 21.0 (IBM, Armonk, NY, USA).

Ethics statement

The Institutional Review Board (IRB) of the Korea Centers for Disease Control and Prevention approved this study (2014-06EXP-02-P-A). Written informed consent was obtained from each participant prior to the survey. Because this web-based survey was performed at a school with a large number of participants, the study was exempt from obtaining informed consent from the students' parents. This consent procedure was approved by the IRB of the KCDC.

RESULTS

Of the 288,909 participants, 31,322 (10.8%) chose appearance as the most serious cause of their stress. The rate of distress about appearance was the lowest in the underweight group (8.8%), and this rate increased along with weight in the direction of obesity (healthy weight, 10.2%; overweight, 15.3%; and obese, 19.2%). Mean age and the variables of sex, region of residence, economic level, parental educational level, smoking, and alcohol consumption differed according to obesity status (each P < 0.001) (Table 1).

In multiple logistic regression analysis, AOR was higher for participants with obesity (AOR for healthy weight = 1.15; AOR for overweight = 1.85; AOR for obese = 2.45; reference = underweight, P < 0.001). The results of simple logistic regression analysis were similar to the results of multiple logistic regression analysis (Table 2).

In the subgroup analysis of boys, those with a healthy weight showed AORs under 1 (AOR = 0.92 [95% CI, 0.85–0.99]), while those who were overweight and obese exhibited AORs greater than 1 (AOR for overweight = 1.26; AOR for obese = 1.66, P < 0.001). In the subgroup analysis of girls, AORs increased as body weight approached obesity (AOR for healthy weight = 1.44; AOR for overweight = 2.71; AOR for obese = 3.71, P < 0.001) (Table 3).

The results for the younger participants (12–14 years old) and older participants (15–18 years old) were comparable. In the younger age group, the AOR for healthy weight was 1.12, that for overweight was 1.92, and that for obese was 2.72 (P < 0.001). In the older age group, the AOR for healthy weight was 1.15, that for overweight was 1.78, and that for obese was 2.28 (P < 0.001) (Table 3).

DISCUSSION

Compared to the results for underweight individuals, the AORs for body dissatisfaction were higher in the healthy weight, overweight, and obese groups with a dose-response relationship. In previous studies, higher BMI was related to body dissatisfaction21, 22 and to psychological distress.23 As stated above, obese people are treated with unjust prejudice and discrimination,7, 8 which could be a chronic stressor and could adversely affect their face and body image. As obesity is becoming an increasing problem in westernized countries, social pressure for thinness also increases.24 Therefore, discrepancies between one's desired and actual weight intensify the distress associated with body image. Hence, the obese participants in this study might be stressed about their appearance.

The subgroup analyses revealed that the AORs for girls were higher than those for boys. In other words, girls may be more stressed about their appearance based on their obesity status. This result can be explained by differences in the social expectation of thinness according to sex.7 Moreover, girls and young women are particularly vulnerable to weight balance issues.25 The results from previous large population-based studies that evaluated the relation between BMI and depression23, 26, 27 and the relation between BMI and body dissatisfaction6 are in accordance with our findings. Istvan et al.26 reported that BMI is related to depression in women but not in men, and Carpenter et al.27 found that underweight men and obese women experienced depression. Notably, the AORs for adolescents of healthy weight were lower and higher than those for the underweight boys and girls, respectively. Thus, a relationship between underweight and distress about appearance was found for boys, whereas a relationship between healthy weight and distress about appearance was obtained for girls. Girls being underweight might be viewed as positive by the media, peers, and family.28 Additionally, underweight women might be less likely to be marginalized in their social environment, whereas underweight men are denounced.29, 30, 31

The results of the subgroup analysis for the younger and older groups were comparable. Shin et al.5 reported similar results for younger participants. Body dissatisfaction was found to be strongly associated with childhood obesity in 413 elementary Korean children. Because obesity-related stigma is persistent from an early part of a child's life,7 the younger adolescents in this study might have exhibited high AORs for the relation between obesity and distress about appearance. Hence, even younger adolescents could have been highly stressed about their appearance, depending on whether they were obese.

This study has various strengths. The study was the first to compare the association between obesity and distress about appearance with a large population-based survey of Korean adolescents (n = 288,909). Sampling was weighted by statisticians to reflect the mother population. We adjusted for age, sex, region of residence, economic level, parental education level, alcohol consumption, and smoking habits, which could act as confounding factors.31, 32 The measure of self-reported weight and height was validated in previous studies,17, 18 and obesity status was identified based on the commonly accepted definition of underweight, overweight, and obese.20 Despite these strengths, this study has several limitations. First, the study used self-reported data pertaining to distress about appearance. This question could be interpreted very differently and not confined to obesity. Furthermore, this was not measured with any objective scale. However, obesity status might be important to appearance, and this item was limited in objectivity, even if it was measured in defined levels. Second, the study was subject to the same limitations that affect all cross-sectional studies, including possible reverse causality; therefore, our calculated ORs should be interpreted with caution. Third, the relationship between body dissatisfaction and self-esteem in adolescents varies across race and ethnicity.12, 31 This result could apply narrowly to similar race-ethnic groups.

In conclusion, obesity is related to distress about appearance. This association is stronger in girls than in boys, and healthy girls show higher ORs than the underweight group. This relation is comparable between the younger and older groups of adolescents.

Funding:This research was supported by Hallym University Research Fund 2017 (HURF-2017-45).

Disclosure:The authors have no potential conflicts of interest to disclose.

Author Contributions:

References

    1. Smolak L. Body image in children and adolescents: where do we go from here? Body Image 2004;1(1):15–28.
    1. Duncan MJ, Al-Nakeeb Y, Nevill AM. Body esteem and body fat in British school children from different ethnic groups. Body Image 2004;1(3):311–315.
    1. Brytek-Matera A. Psychological predictors of body image dissatisfaction in women suffering from eating discorders. Bull Soc Sci Med Grand Duche Luxemb. Spec No 2010;1(1):181–191.
    1. Vander Wal JS, Thelen MH. Predictors of body image dissatisfaction in elementary-age school girls. Eat Behav 2000;1(2):105–122.
    1. Shin NY, Shin MS. Body dissatisfaction, self-esteem, and depression in obese Korean children. J Pediatr 2008;152(4):502–506.
    1. Calzo JP, Sonneville KR, Haines J, Blood EA, Field AE, Austin SB. The development of associations among body mass index, body dissatisfaction, and weight and shape concern in adolescent boys and girls. J Adolesc Health 2012;51(5):517–523.
    1. Fabricatore AN, Wadden TA. Psychological aspects of obesity. Clin Dermatol 2004;22(4):332–337.
    1. Puhl R, Brownell KD. Bias, discrimination, and obesity. Obes Res 2001;9(12):788–805.
    1. Davison KK, Birch LL. Weight status, parent reaction, and self-concept in five-year-old girls. Pediatrics 2001;107(1):46–53.
    1. Chng SC, Fassnacht DB. Parental comments: relationship with gender, body dissatisfaction, and disordered eating in Asian young adults. Body Image 2016;16:93–99.
    1. Fung SS, Stewart SM, Ho S, Wong JP, Lam T. Body dissatisfaction, maternal appraisal, and depressive symptoms in Hong Kong adolescents. Int J Psychol 2010;45(6):453–460.
    1. Choi E, Choi I. The associations between body dissatisfaction, body figure, self-esteem, and depressed mood in adolescents in the United States and Korea: a moderated mediation analysis. J Adolesc 2016;53:249–259.
    1. Holliday R, Elfving-Hwang J. Gender, globalization and aesthetic surgery in South Korea. Body Soc 2012;18(2):58–81.
    1. ISAPS international survey on aesthetic/cosmetic procedures performed in 2015. [Updated 2016]. [Accessed March 6, 2018].
    1. Adolescent statistics 2011. [Updated 2011]. [Accessed July 26, 2016].
    1. Wardle J, Haase AM, Steptoe A. Body image and weight control in young adults: international comparisons in university students from 22 countries. Int J Obes 2006;30(4):644–651.
    1. Bae J, Joung H, Kim JY, Kwon KN, Kim Y, Park SW. Validity of self-reported height, weight, and body mass index of the Korea youth risk behavior Web-based survey questionnaire. J Prev Med Public Health 2010;43(5):396–402.
    1. Bae J, Joung H, Kim JY, Kwon KN, Kim YT, Park SW. Test-retest reliability of a questionnaire for the Korea youth risk behavior Web-based survey. J Prev Med Public Health 2010;43(5):403–410.
    1. Reliability and validity of the Korea youth risk behavior Web-based survey questionnaire 2009. [Updated 2009]. [Accessed March 6, 2018].
    1. About BMI for children and teens. [Updated 2015]. [Accessed July 26, 2016].
    1. Neumark-Sztainer D, Story M, Hannan PJ, Perry CL, Irving LM. Weight-related concerns and behaviors among overweight and nonoverweight adolescents: implications for preventing weight-related disorders. Arch Pediatr Adolesc Med 2002;156(2):171–178.
    1. Wardle J, Cooke L. The impact of obesity on psychological well-being. Best Pract Res Clin Endocrinol Metab 2005;19(3):421–440.
    1. Kim T, Kim JJ, Kim MY, Kim SK, Roh S, Seo JS. A U-shaped association between body mass index and psychological distress on the multiphasic personality inventory: retrospective cross-sectional analysis of 19-year-old men in Korea. J Korean Med Sci 2015;30(6):793–801.
    1. Friedman KE, Reichmann SK, Costanzo PR, Musante GJ. Body image partially mediates the relationship between obesity and psychological distress. Obes Res 2002;10(1):33–41.
    1. Wane S, van Uffelen JG, Brown W. Determinants of weight gain in young women: a review of the literature. J Womens Health (Larchmt) 2010;19(7):1327–1340.
    1. Istvan J, Zavela K, Weidner G. Body weight and psychological distress in NHANES I. Int J Obes Relat Metab Disord 1992;16(12):999–1003.
    1. Carpenter KM, Hasin DS, Allison DB, Faith MS. Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study. Am J Public Health 2000;90(2):251–257.
    1. Mond JM, Hay PJ, Rodgers B, Owen C, Beumont PJ. Assessing quality of life in eating disorder patients. Qual Life Res 2005;14(1):171–178.
    1. Furnham A, Badmin N, Sneade I. Body image dissatisfaction: gender differences in eating attitudes, self-esteem, and reasons for exercise. J Psychol 2002;136(6):581–596.
    1. Kostanski M, Fisher A, Gullone E. Current conceptualisation of body image dissatisfaction: have we got it wrong? J Child Psychol Psychiatry 2004;45(7):1317–1325.
    1. van den Berg PA, Mond J, Eisenberg M, Ackard D, Neumark-Sztainer D. The link between body dissatisfaction and self-esteem in adolescents: similarities across gender, age, weight status, race/ethnicity, and socioeconomic status. J Adolesc Health 2010;47(3):290–296.
    1. Kim I, Bahk J, Kim YY, Lee J, Kang HY, Lee J, et al. Prevalence of overweight and income gaps in 245 districts of Korea: comparison using the National Health Screening Database and the Community Health Survey, 2009–2014. J Korean Med Sci 2018;33(1):e3
Cited by
Publication Types
MeSH Terms
Metrics
Share
Figures

slide

1 / 1

Tables
ORCID IDs