The Journal of School Nursing2022, Vol. 38(4) 397–409© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211003800journals.sagepub.com/home/jsn
This study examined mediating effects of body weight control behaviors in the relationship between body weight perception and health-related behaviors among 11,458 U.S. adolescents from the 2010 National Youth Physical Activity and Nutrition Survey. Parallel multiple mediation analysis was performed for the secondary data analysis. Nearly one third of adolescents (32.5%) had overweight or obesity; one quarter (25.0%) perceived themselves as slightly overweight and 5.1% thought they were very overweight. More girls (58.6%) had tried to lose weight than boys (32.3%), while boys were more physically active than girls. Healthy and unhealthy weight control behaviors significantly mediated the relationship between adolescents’ body weight perception and health-related behaviors (physical activity and screen time). Teachers and parents should help adolescents have accurate weight perception and utilize reliable and healthy weight control strategies. Future studies should consider the intercorrelated relationships among adolescents’ perceptions and behaviors regarding weight to provide successful weight control intervention programs.
Keywords
adolescents, mediation analysis, National Youth Physical Activity and Nutrition Survey, physical activity, screen time, body weight control behaviors, body weight perception
One in five children in the United States has obesity, and the prevalence of obesity among youth has increased over the past several decades (Centers for Disease Control and Prevention [CDC], 2019; Fryar et al., 2018). As children age, their obesity rates also increase, as reflected in the fact that one fifth of adolescents (20.6%) have obesity, followed by school-aged children (18.4%) and preschool children (13.9%; Hales et al., 2017). Based on simulation models, Ward et al. (2017) predicted that more than half of today’s children (57.3%) would become adults with obesity by the age of 35. Furthermore, approximately 80% of adolescents with obesity are expected to become adults with obesity (Simmonds et al., 2016).
Childhood obesity is a complicated problem associated with multiple factors such as genetics and healthy behaviors (Anderson, 2018; Kumar & Kelly, 2017). Therefore, understanding relationships among these factors is critical to reverse the childhood obesity epidemic. In this study, we refer to health-related behaviors as physical activity and screen time. Physical inactivity is one of the manageable lifestyle factors that contribute to energy imbalance and childhood obesity (Daniels et al., 2015; Kumar & Kelly, 2017). Physical activity helps children in developing physiological health, maintaining healthy body weight, and reducing mental health problems (World Health Organization [WHO], 2020). However, the moderate to vigorous physical activity (MVPA) time per day decreases as children become adolescents (Janssen et al., 2019). Consequently, only one third of American adolescents (35.3% of boys and 17.5% of girls) in the United States meet the CDC guideline of at least 60 min of MVPA per day (Foster et al., 2018; Kann et al., 2018).
Excessive screen time has also been associated with a higher risk of developing childhood obesity (Fang et al., 2019; Kumar & Kelly, 2017). Although experts recommend that adolescents’ screen time should be limited to 120 min per day (Chassiakos et al., 2016; Weihrauch-Bluher et al., 2018), 43% of American adolescents exceed this limit (Baiden et al., 2019). Almost all (95%) adolescents reported that they have or have access to a smartphone, and 45% of them use the internet “almost constantly†(Pew Research Center, 2018). A child with excessive screen time is more likely to eat unhealthy foods and to experience sleep deprivation, which also significantly contribute to a child’s higher body mass index (BMI; Baiden et al., 2019; Cameron et al., 2016; Mayne et al., 2020 Parent et al., 2016).
Weight misperception is a phenomenon in which there is a discrepancy between an individual’s actual weight and their perceived weight (Hahn et al., 2018). More than half (55.2%) of American children (aged 8–17) with overweight or obesity misperceived their weight as normal (Ling & Stommel, 2019). In addition, girls are more likely to overestimate their weight than boys (Dues et al., 2019). Dues et al. (2019) reported that adolescents who misperceive their weight are more likely to engage in unhealthy dietary behaviors and physical inactivity. Adolescents who feel either under- or overweight are more likely to engage in unhealthy weight control behaviors than those who feel they are at the right weight (Kennedy et al., 2019). Furthermore, perceived overweight is not only related to more weight loss attempts but also with repetitive weight gain (Haynes et al., 2018). The literature using a national sample found that adolescents who perceive themselves as overweight or obese are engaged in less physical activity and more screen time (Fan & Jin, 2015; Xu et al., 2018). Therefore, it is imperative to explore adolescents’ weight perceptions and examine how they are related to childhood obesity prevention.
Weight control behaviors, including attempts to maintain or lose weight, are widespread among adolescents (Lampard et al., 2016). As the prevalence of obesity among adolescents has increased, the number of adolescents who have attempted weight loss has also increased. McDow et al. (2019) reported that 37.6% of U.S. adolescents aged 16–19 tried to lose weight in 2013–2016. Furthermore, Kennedy et al. (2019) found that approximately 23% of U.S. adolescents engage in unhealthy weight control behaviors such as fasting, using diet pills, and vomiting or taxing laxatives. In particular, more adolescent girls (45.2%) reported weight loss attempts than adolescent boys (30.1%; McDow et al., 2019).
Adopting a range of weight control behaviors has the potential to trigger positive and/or negative health consequences (Lampard et al., 2016). For example, adolescents who used healthy weight control behaviors (e.g., physical activity, eat more fruits and vegetables) significantly decreased their BMI (Chae et al., 2018; Ojeda-Rodriguez et al., 2018). However, the use of unhealthy weight control behaviors (e.g., taking diet pills, fasting, and smoking) is associated with BMI rebound and an increased risk of developing eating disorders (Levinson et al., 2020; Nagata et al., 2018).
Previous studies have found a significant and direct relationship between children’s weight perception and weight control behaviors, weight perception and health-related behaviors, and weight control behaviors and health-related behaviors (Dues et al., 2019; Hahn et al., 2018; Haynes et al., 2018; Kennedy et al., 2019). However, the interrelationships among these factors have not yet been examined. Furthermore, considering the increased number of adolescents’ weight loss attempts and the health risks associated with weight control behaviors, it is critical to examine factors related to adolescents’ weight control behaviors. However, it remains unknown how adolescents’ healthy and unhealthy weight control behaviors are linked with their body weight perception and health-related behaviors. Thus, mediation analysis was applied to examine the mediating role of adolescents’ weight control behaviors in the relationship between body weight perception and health-related behaviors. The purpose of this study was to (1) describe U.S. adolescents’ body weight perception, body weight control behaviors, and health-related behaviors; (2) examine associations of U.S. adolescents’ body weight perception, body weight control behaviors, and health-related behaviors; and (3) examine the potential mediating effects of U.S. adolescents’ weight control behaviors in the relationship between body weight perception and specific health-related behaviors (physical activity and screen time).
The hypotheses of this study examining the mediating effects are as follows:
Hypothesis 1 (H1, x ⟶ m1 ⟶ y1): Adolescents’ healthy weight control behaviors (m1) mediate the relationship between body weight perception (x) and physical activity (y1).
Hypothesis 2 (H2, x ⟶ m1 ⟶ y2): Adolescents’ healthy weight control behaviors (m1) mediate the relationship between body weight perception (x) and screen time (y2).
Hypothesis 3 (H3, x ⟶ m2 ⟶ y1): Adolescents’ unhealthy weight control behaviors (m2) mediate the relationship between body weight perception (x) and physical activity (y1).
Hypothesis 4 (H4, x ⟶ m2 ⟶ y2): Adolescents’ unhealthy weight control behaviors (m2) mediate the relationship between body weight perception (x) and screen time (y2).
This study performed a cross-sectional secondary data analysis from the National Youth Physical Activity and Nutrition Survey (NYPAN), which is based on a representative sample of U.S. students in Grades 9–12 that used a three-stage cluster sample design. The sample design and procedures are reported elsewhere (Park & Park, 2020). A total of 11,458 high school students from 138 public and private schools participated. Students completed a 120-item paper-and-pencil survey questionnaire. The items consisted of adolescents’ weight perception; health-related behaviors such as physical activity, screen time, and dietary habits; weight control behaviors; and factors that contribute to these behaviors (e.g., parental support for physical activity). The NYPAN items were adopted from the Youth Risk Behavior Study and the psychometrics for the study are reported elsewhere (Brener et al., 2002; Demissie et al., 2013). Human subjects’ approval was obtained from a university institutional review board prior to conducting the data analysis.
Demographic characteristics included the individual adolescent’s age, sex, and race/ethnicity (Hispanic/Latino, non-Hispanic White, non-Hispanic Black, Asian, and Other). Body weight and height were measured by trained professionals following a standardized protocol. BMI was calculated following the CDC protocol for the 2009 Youth Risk Behavior Surveillance System (CDC, 2010). Adolescents’ body weight status was categorized into four groups: underweight (BMI < 5th percentile), normal weight (5th percentile ≥ BMI < 85th percentile), overweight (85th percentile ≥ BMI < 95th percentile), and obese (BMI ≥ 95th percentile; CDC, 2018).
Body weight perception was measured using the question, “How do you describe your weight?†with the response options “very underweight,†“slightly underweight,†“about the right weight,†“slightly overweight,†and “very overweight.†Body weight perception was grouped into four categories (1 = underweight, 2 = about the right weight, 3 = slightly overweight, and 4 = very overweight).
Body weight management attempts were measured through the question, “Which of the following are you trying to do about your weight?†Response choices included: “lose weight,†“gain weight,†“stay the same weight,†or “I am not trying to do anything about my weight.â€
Body weight control behaviors were assessed through 10 questions about the adolescent’s efforts to lose weight during the past 30 days. Healthy weight control behaviors were measured by the respondents’ behaviors that contribute to losing weight by promoting health-related behaviors (five items). Adolescents who engaged in healthy weight control behaviors answered “yes†(1) while those who did not responded “no†(2). The items for healthy weight control behaviors were presented with the question frame, “During the past 30 days, did you: exercise to lose weight or to keep from gaining weight? eat less food, fewer calories, or foods low in fat to lose weight or to keep from gaining weight? eat more fruits and vegetables to lose weight or keep from gaining weight? eat fewer calories to lose weight or keep from gaining weight? or drink more water to lose weight or keep from gaining weight?†For the five items of healthy weight control behaviors, a “yes†response was coded as 1 and a “no†response was coded as 0. Based on the summation of scores, higher scores indicate engagement in more kinds of healthy weight control behaviors.
Unhealthy weight control behaviors were assessed by the adolescent’s engaging in behaviors to reduce their weight that compromised their health (five items). The items of unhealthy weight control behaviors included: “During the past 30 days, did you: skip meals to lose weight or keep from gaining weight? smoke cigarettes to help you lose weight or keep from gaining weight? go without eating for 24 hr or more (also called fasting) to lose weight or keep from gaining weight? take any diet pills, powders, or liquids without a doctor’s advice to lose weight or keep from gaining weight? or vomit or take laxatives to lose weight or keep from gaining weight?†For the five items of unhealthy weight control behaviors, a “yes†response was coded as 1 and a “no†response was coded as 0. Based on the summation of scores, higher scores indicate involvement in more kinds of unhealthy weight control behaviors.
Health-related behaviors were measured using questions on the adolescent’s physical activity and screen time. Physical activity was assessed through responses to three items addressing the following: frequency of moderate physical activity, vigorous physical activity, and musclestrengthening physical activity during the past 7 days. The items included “How many days were you physically active for a total of at least 60 min per day? (add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time)†for measuring moderate physical activity; “How many days did you exercise or participate in physical activity for at least 20 min that made you sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar aerobic activities?†for measuring vigorous physical activity; and “How many days did you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weight lifting?†for measuring musclestrengthening physical activity. Response choices for the items related to physical activity included a 7-point Likerttype scale in which more frequent activity was given a higher score (1 = 1 day and 7 = 7 days). Based on the summation of scores, higher scores indicate engagement in more physical activity. Screen time was measured through three items addressing the following: “On an average school day, how many hours do you spend playing video or computer games? watching DVDs or videos? and watching television?†Hours of screen time was measured on a Likerttype scale with 1 = no play, 2 = < 1 hr per day, 3 = 1 hr per day, 4 = 2 hr per day, 5 = 3 hr per day, 6 = 4 hr per day, and 7 = ≥ 5 hr per day. Based on the summation of scores, higher scores indicate longer screen time.
Study data were analyzed using SPSS Version 26.0, AMOS Version 26.0, and Mplus Version 8.4. Unpaired t test and χ2 test were used to compare body weight control behaviors and health-related behaviors between boys and girls. Pearson correlation coefficients (r) and Spearman’s Ï correlation (rs) were used to examine associations among variables. Parallel multiple mediation analysis was performed to assess whether the association between weight perception and health-related behaviors, including physical activity and screen time, is mediated by weight control behaviors. Subgroup analyses were also conducted for multiple mediation analyses between boys and girls. The full information maximum likelihood (FIML) estimation was used for the mediation analysis, and FIML is effective in dealing with both missing data and non-normal data. The Monte Carlo calculation was conducted to examine the significance of mediating effects (Preacher & Selig, 2012). Not including zero in the Monte Carlo 95% confidence interval (CI) indicates a meaningful mediating effect at a significance level of .05. Adjustment of the sample weights was applied for the data analyses.
Table 1 summarizes the sociodemographic characteristics of study participants. About three quarters of the sample (75.8%) fell between the ages of 15 and 17 years, and the sample was fairly evenly distributed between males and females. The ethnic breakdown of the sample included a slight majority of non-Hispanic Whites (56.6%), with smaller percentages of non-Hispanic Blacks (14.6%), Hispanics/Latinos (11.2%), Asians (3.3%), and Others (12.4%). Based on the CDC protocol for BMI references, 2.2% of adolescents had underweight, 53.6% had normal weight, 15.7% had overweight, and 16.8% had obesity. The prevalence of overweight or obesity was highest among Hispanic/Latino adolescents (20.9%, 21.1%, respectively), followed by non-Hispanic Blacks (18.6%, 23.1%), non- Hispanic Whites (17.6%, 16.3%), and Asians (16.5%, 9.7%).
Approximately 45.2% of adolescents had tried to lose weight in the previous month. In particular, the majority of participants who perceived themselves as slightly overweight (n = 2,354; 84.7%) or very overweight (n = 513; 85.2%) reported that they had attempted weight loss. Except for the experience of weight management attempts, the general characteristics of boys and girls were similar. More girls (58.6%) responded that they had tried to lose weight than boys (32.3%), while three times more boys (27.5%) had tried to gain weight than girls (5.5%).
Regarding body weight perception, 12.7% of our sample of adolescents perceived themselves as underweight, 53.3% as about the right weight, 25.0% as slightly overweight, and 5.1% as very overweight (Table 1). Supplemental Table 1 compares adolescents’ perceived weight with their measured BMI. Among the adolescents who perceived themselves as the right weight, 77.6% were normal weight based on their BMI determined by height and weight measures. Among the adolescents who perceived themselves as slightly or very overweight, 78.0% had overweight or obesity according to their measured BMI.
In terms of measured BMI, among the adolescents who had normal weight, 71.6% perceived themselves as the right weight. Among the adolescents who had overweight or obesity, 65.5% thought they had overweight or obesity. Among girls with overweight or obesity, 72.6% recognized themselves as slightly or very overweight. However, among boys with overweight or obesity, only 57.8% correctly recognized their weight.
Table 2 presents the frequencies of body weight control behaviors in the sample. Among all respondents, the most commonly reported healthy weight control behavior was exercise (56.0%), followed by drinking more water (39.4%), eating less food (37.7%), eating more fruits and vegetables (33.0%), and consuming fewer calories (31.4%). The most common unhealthy weight control behavior was skipping meals (21.2%), followed by fasting (8.0%), smoking cigarettes (4.9%), taking diet pills (4.4%), and vomiting or taking laxatives (3.5%). Girls (M = 2.17, SD = 1.71) were involved in more kinds of healthy weight control behaviors than boys (M = 1.55, SD = 1.59), t = 19.25, p < .001.
There were gender differences in healthy and unhealthy weight control behaviors. Girls were more engaged than boys in each healthy weight control behavior (e.g., 12% higher in exercise and 18% higher in eating less food). Among unhealthy weight control behaviors, girls were more likely than boys to skip meals (28.3% vs. 16.0%) and to engage in fasting (9.6% vs. 7.2%). Girls (M = 0.72, SD = 0.85) were also involved in more unhealthy weight control behaviors (M = 0.60, SD = 0.99) than boys (M = 0.60, SD = 0.99), t = 6.90, p < .001.
Table 3 shows the frequencies of health-related behaviors in the study sample. Regarding physical activity, participants responded that they had engaged in moderate physical activity more often in the previous week (M = 4.14 days, SD = 1.86) than in vigorous physical activity (M = 4.75 days, SD = 2.23) or muscle-strengthening physical activity (M = 3.73 days, SD = 2.31). Additionally, watching television (M = 3.80, SD = 1.77) was the most frequently reported screen time behavior.
Gender differences were observed in physical activity and screen time. Overall, boys reported a higher frequency of all levels of physical activity than girls (t = –32.13, p < .001). The level of engagement in physical activity in the previous week for boys was 14.13 (SD = 5.30), while for girls it was 10.98 (SD = 5.12). Among screen time behaviors, boys (M = 3.56, SD = 1.69) were more likely to play video games or use the computer than girls (M = 3.24, SD = 1.70). In contrast, girls were more likely to watch DVDs or videos than boys (M = 3.40, SD = 1.96 vs. M = 3.21, SD = 1.80, respectively). Moreover, girls (M = 3.84, SD = 1.82) spent more time watching television than boys (M = 3.76, SD = 1.73). However, when different kinds of screen time were summed, no significant differences were found in screen time between boys and girls (t = –0.27, p = .791).
Table 4 shows associations among U.S. adolescents’ body weight perceptions, weight control behaviors, and health-related behaviors. Among all adolescents, healthy weight control behaviors (rs = .36, p < .001) and unhealthy weight control behaviors (rs = .25, p < .001) were positively associated with body weight perception. Physical activity was positively associated with healthy weight control behaviors (r = .01, p < .001) and negatively associated with unhealthy weight control behaviors (r = –.03, p < .001), while screen time was negatively associated with healthy weight control behaviors (r = –.06, p < .001) and positively associated with unhealthy weight control behaviors (r = .04, p < .001). Physical activity and screen time were inversely correlated (r = –.16, p < .001).
Table 5 and Figures 1–3 show how both healthy and unhealthy weight control behaviors mediated the relationship between body weight perception and health-related behaviors. Among all adolescents (Figure 1), the more the respondents perceived themselves as weighing more, the more they engaged in healthy (b = .78, p < .001) and unhealthy weight control behaviors (b = .23, p < .001). In addition, healthy weight control behaviors were significantly associated with increased physical activity (b = .09, p = .049) and decreased screen time (b = –.24, p < .001). Conversely, unhealthy weight control behaviors were significantly associated with decreased physical activity (b = – .25, p = .016) and increased screen time (b = .41, p < .001). Significances of the mediating effects of healthy and unhealthy weight control behaviors among all adolescents were presented based on the Monte Carlo approach. As presented in Table 5, all the multiple mediating effects (H1: b = .070, Monte Carlo 95% CI [0.002, 0.140]; H2: b = –.091, Monte Carlo 95% CI [–0.273, –0.112]; H3: b = –.058, Monte Carlo 95% CI [–0.111, –0.010]; and H4: b = .093, Monte Carlo 95% CI [0.053, 0.139]) are considered to be statistically significant. Therefore, these multiple mediating analyses revealed that healthy and unhealthy weight control behaviors significantly mediated the relationship between body weight perception and health-related behaviors.
Among boys (Figure 2), the more they perceived themselves as weighing more, the more they engaged in both healthy (b = .73, p < .001) and unhealthy weight control behaviors (b = .17, p < .001). In addition, healthy weight control behaviors were significantly associated with increased physical activity (b = .15, p = .019) and decreased screen time (b = –.15, p = .025). Although unhealthy weight control behaviors had no effect on physical activity (b = – .15, p = .260), they were significantly associated with increased screen time (b = .40, p < .001). Significances of the mediating effects of healthy and unhealthy weight control behaviors among boys based on the Monte Carlo approach are shown in Table 5. Except for the H3 (x ⟶ m2 ⟶ y1 ) path, the other three multiple mediating effects (H1: b = .107, Monte Carlo 95% CI [0.017, 0.201]; H2: b = –.113, Monte Carlo 95% CI [–0.220, –0.013]; and H4: b = .070, Monte Carlo 95% CI [0.032, 0.115]) are considered to be statistically significant.
As with the boys, among girls (Figure 3), the more they perceived themselves as weighing more, the more they engaged in both healthy (b = .73, p < .001) and unhealthy weight control behaviors (b = .26, p < .001). Moreover, healthy weight control behaviors were significantly associated with increased physical activity (b = .43, p < .001) and decreased screen time (b = –.30, p < .001). Conversely, unhealthy weight control behaviors were significantly associated with decreased physical activity (b = –.30, p = .012) and increased screen time (b = .42, p < .001). Significances of the mediating effects of healthy and unhealthy weight control behaviors among girls based on the Monte Carlo approach are also presented in Table 5. All the multiple mediating effects (H1: b = 0.315, Monte Carlo 95% CI [0.219, 0.408]; H2: b = –0.215, Monte Carlo 95% CI [–0.300, –0.134]; H3: b = –0.077, Monte Carlo 95% CI [–0.145, –0.016]; and H4: b = 0.107, Monte Carlo 95% CI [0.050, 0.171]) are considered to be statistically significant.
Among both boys and girls, the strongest mediating effect was shown on the H1 (x ⟶ m1 ⟶ y1 ), followed by the H2 (x ⟶ m1 ⟶ y2 ). This indicates that healthy weight control behavior plays a more important mediating role than unhealthy weight control behavior in the relationship between body weight perception and health-related behaviors among adolescents (Table 5).
This study was conducted to examine the mediating effects of U.S. adolescents’ weight control behaviors in the relationship between body weight perception and specific health-related behaviors (physical activity and screen time). This study supports the first and second hypotheses regarding the mediating role of healthy weight control behaviors on the relationship between body weight perception and health-related behaviors. This study also supports the third and fourth hypotheses regarding the mediating role of unhealthy weight control behaviors on the relationship between body weight perception and health-related behaviors. In addition, healthy weight control behaviors showed a more powerful mediating effect than unhealthy weight control behaviors. Adolescents who perceived their weights as higher were more engaged in healthy and unhealthy weight control behaviors. Furthermore, adolescents who engaged in healthy weight control behaviors also engaged in other health-promoting behaviors such as increased physical activity and decreased screen time. In contrast, those who used unhealthy weight control behaviors showed an inverse relationship (decreased physical activity and increased screen time). Those relationships indicate that using healthy weight control behaviors is critical in promoting healthy behaviors among adolescents. We could not examine the mediating effect on adolescents’ weight outcomes because their weight status was measured only at one point. Studies that measure weight at multiple time points would enable a longitudinal approach to examining the long-term and multivariate factors affecting adolescents’ weight perception, weight control behaviors, and health-related behaviors.
In this study, almost one third of adolescents perceived themselves as slightly overweight (25.0%) or very over-weight (5.1%), and 45.2% of adolescents had attempted to lose weight. Notably, the majority of adolescents who perceived themselves as slightly overweight (84.7%) or very overweight (85.2%) had tried to lose weight. This is similar to the report from a national study that the majority (77.7%) of U.S. adolescents with obesity had tried to lose weight (McDow et al., 2019). Weight perception drives adolescents to choose their weight control behaviors, irrespective of actual body weight. In particular, adolescents who have inaccurate weight perception (overestimation or underestimation) are more likely to use unhealthy weight control behaviors (Fan & Jin, 2015; Shin & Nam, 2015). Brown et al. (2016) also reported that adolescents’ motivation for weight loss (e.g., a desire to be healthier or in response to teasing) determines weight control behaviors. Additionally, adolescents who attempted to lose weight showed signs of serious depression and low self-esteem (Yeatts et al., 2016). Thus, routine screening and assessment for adolescents’ perceived weight and unhealthy weight control behaviors is warranted in clinical settings; these weight misperceptions and unhealthy weight control behaviors should be viewed as red flags for adolescent mental health (Utter et al., 2012). Meanwhile, adolescents who have high self-esteem are significantly more likely to exclusively engage in healthy weight control behaviors than those with low self-esteem (Lampard et al., 2016). This result can be explained by the fact that if adolescents voluntarily decide to lose weight rather than it being imposed by someone else, they tend to choose healthy weight control behaviors. Therefore, further studies should examine factors associated with having an inaccurate weight perception, explore the motivation for weight loss, and identify the decision-making process in selecting healthy and/or unhealthy weight control behaviors to help adolescents make the right decision for weight control.
Adolescents in our study reported that they used more healthy weight control behaviors than unhealthy ones in their attempts to lose weight. Similar to the empirical evidence from previous studies, exercise (56.0%) was the most common healthy weight control behavior reported (Brown et al., 2016; McDow et al., 2019). Among unhealthy weight control behaviors, skipping meals (21.2%) was the most frequent unhealthy weight control behavior, followed by fasting (8.0%). Unfortunately, these behaviors are known to be ineffective in weight management and can even be detrimental to health such as raising the risk of developing eating disorders (Levinson et al., 2020; Nagata et al., 2018).
In accordance with the findings from the literature (McDow et al., 2019), weight loss attempts were more prevalent among girls (58.6%) than among boys (32.3%) in this study. Furthermore, girls were more engaged in both healthy and unhealthy weight control behaviors. The different perspectives on weight status may explain the observed gender discrepancies in weight control behaviors. For example, adolescent girls are more likely to overestimate their weight than adolescent boys (Dues et al., 2019; Shin & Nam, 2015). Furthermore, social and cultural norms in favor of thinness lead to body dissatisfaction and may influence adolescent girls to lose weight (Tadena et al., 2020). Consequently, girls use more unhealthy weight control behaviors, which are perceived as faster and easier ways to lose weight. Meanwhile, boys may use healthy weight control behaviors (e.g., exercise or eating lower calorie foods) to improve their physical appearance with a desire for having a muscular body shape, rather than for just losing weight. Thus, programs to redirect a distorted body image and disseminate evidence-based resources in selecting appropriate weight control behaviors should be provided.
We found that adolescents who used healthy weight control behaviors are more likely to be engaged in physical activity and less screen time. This can be explained by the fact that adolescents who used healthy weight control behaviors may also promote physical activity and limit their screen time to boost their weight control efforts and expedite weight loss. Meanwhile, adolescents who used unhealthy weight control behaviors may not engage in healthy behaviors because they believe that adopting unhealthy weight control behaviors is enough to lose weight without further effort such as physical activity. Additionally, they may lack the energy to engage in health-related behaviors due to unhealthy weight control behaviors such as fasting or vomiting. Therefore, the importance of promoting healthy behaviors rather than entirely relying on unhealthy weight control behaviors should be emphasized to achieve desired weight loss outcomes and improve health.
Compared to boys, girls’ body weight perception was more strongly associated with healthy weight control behaviors, which were also related to higher physical activity and lower screen time. As reported in Supplemental Table 1, girls were more likely to have accurate body weight perception than boys. Therefore, relationships among variables could appear stronger in girls than in boys. Thus, motivating boys with overweight or obesity to accurately recognize their body weight should be prioritized in promoting healthy weight control behaviors and other health-related behaviors.
Physical activity levels are generally lower among adolescent girls than among adolescent boys (WHO, 2016). Similarly, in our study, boys were more engaged in all types of physical activity than girls. However, a higher percentage of girls responded that they chose exercise for controlling their body weight than did boys. In other words, boys engaged in physical activity for both weight loss and healthy behavior, while girls mainly engaged in physical activity to achieve weight loss goals. Therefore, it is possible that the mediating effects of weight control behaviors on health-related behaviors among boys in this study are weaker than those among girls. Moreover, Spencer et al. (2015) reviewed the existing literature and concluded that young girls need to negotiate gender roles and have a complicated relationship with physical activity. However, the role of direct and indirect factors in shaping gender differences in physical activity is understudied. Further research is needed to better understand how to reduce the adolescent gender gap in physical activity.
Parental support and appropriate role modeling in physical activity and screen time can significantly improve children’s behaviors (Pereira et al., 2017; Schoeppe et al., 2016). Therefore, efforts to establish a non-obesogenic environment and provide family-based interventions through parental role modeling and support are needed to promote adolescents’ health-related behaviors. For example, these may include participation in family physical activities (i.e., bike riding or jogging) and designated media-free times together (i.e., eating dinner or driving) as well as media-free locations at home (i.e., bedrooms). We also suggest the implementation of school-based interventions to promote physical activity during adolescents’ time spent in school. Teachers and parents should proactively dialogue to provide support for increasing adolescents’ physical activity and decreasing screen time at school and in the home.
This study had several limitations. Since we used cross-sectional data, our ability to make causal inferences regarding the results is limited (Fairchild & McDaniel, 2017). Data on body weight control and health-related behaviors were self-reported by adolescents. They may have responded more favorably because of social desirability influence. In future studies, these behaviors should be assessed using objective measures (e.g., accelerometer) along with self-report to increase credibility. Both weight loss and weight maintenance attempts were asked in one item when assessing weight control behaviors (e.g., during the past 30 days, did you exercise to lose weight or to keep from gaining weight?). Since weight loss and weight maintenance can have different motivations regarding weight control, the pathways between weight control behaviors and health-related behaviors may be different. Therefore, weight loss and weight maintenance should be assessed in separate items in future studies. Also, there was no item asking about motivations for weight control behaviors. Because of the nature of a cross-sectional study design, weight status was measured only at one point. Thus, we could not analyze the effects of weight control behaviors on weight status in a longitudinal manner. Despite these limitations, this study had many strengths, including that we examined weight control and health-related behaviors among U.S. adolescents from a large nationally representative sample. The findings on the mediating role of weight control behaviors and the gender gaps in weight control and health-related behaviors can be used as a foundation in developing childhood obesity prevention programs.
Our findings offer important clinical implications for health care providers including school nurses. Comprehensive interventions should be provided, such as assessing adolescents’ perceptions of their weight status and health-related behaviors, raising self-awareness of their weight, and helping them to recognize the importance of promoting positive health-related behaviors. Additionally, teachers and parents should help adolescents to perceive their weight accurately and to utilize reliable and healthy weight control strategies. Specific actions may include school nurses using body silhouettes to explore adolescents’ body image in relation to body dissatisfaction that could lead to unhealthy weight control behaviors. Discussing concerns of excessive weight and weight loss plans with adolescents at regular intervals may help to discourage unhealthy weight control behaviors such as fasting and meal skipping. Furthermore, teachers and parents should avoid delivering negative messages on adolescents’ weight by using teasing or modeling a negative parental feeding style, such as food restriction that could motivate adolescents to adopt unhealthy weight control behaviors.
So Hyun Park and Hanjong Park contributed to conception or design, acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and agrees to be accountable for all aspects of work ensuring integrity and accuracy. Faith Myles contributed to acquisition, analysis, or interpretation; drafted the manuscript; critically revised the manuscript; gave final approval; and Agrees to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was financially supported by the Catholic Medical Center Research Foundation made in the program year of 2018.
Hanjong Park, PhD, RN https://orcid.org/0000-0003-0896-654X
Supplemental material for this article is available online.
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So Hyun Park, PhD, RN, is an associate professor at College of Nursing, Florida State University, Tallahassee, FL, USA.
Hanjong Park, PhD, RN, is an assistant professor at College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea.
Myles Faith, PhD, is a chair and professor in the Department of Counseling, School, and Educational Psychology, Graduate School of Education, University at Buffalo—The State University of New York, Buffalo, NY, USA.
1 College of Nursing, Florida State University, Tallahassee, FL, USA
2 College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea
3 Department of Counseling, School, and Educational Psychology, Graduate School of Education, University at Buffalo–The State University of New York, NY, USA
Corresponding Author:
Hanjong Park, PhD, RN, College of Nursing, The Catholic University of Korea, 222 Banpo-daero, Seocho-Gu, Seoul 06591, Republic of Korea.Email: hpark@catholic.ac.kr