PROPOSAL SKRIPSI

META ANALISIS : PENGARUH OBESITAS TERHADAP

PSIKOSOSIAL REMAJA

DISUSUN OLEH :

NURQAULAN KARIMA GUSTARI

NIM : P05130218034

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLTEKKES KEMENKES BENGKULU
PRODI SARJANA TERAPAN DAN DIETETIKA GIZI
2021 / 2022
 KATA PENGANTAR

Segala puji dan syukur kehadirat Allah SWT yang telah melimpahkan
rahmat-Nya, sehingga saya dapat Yang Diajukan Untuk menyelesaikan
pembuatan Proposal Skripsi Meta Analisis : Pengaruh Obesitas terhadap
Psikososial Remaja untuk memenuhi tugas akhir Skripsi.
Saya menyadari bahwa makalah ini masih jauh dari kata sempurna,
kritik dan saran dari semua pihak sangat saya harapkan demi kesempurnaan
dari proposal ini. Semoga proposal sederhana ini dapat dipahami bagi
siapapun yang membacanya. Sekiranya proposal yang telah disusun ini dapat
bermanfaat bagi kita semua.
Akhir kata saya sampaikan terima kasih dosen pembimbing mata kuliah
dan kepada semua pihak yang telah berperan serta dalam pembuatan makalah
ini dari awal sampai akhir. Semoga Allah SWT senantiasa meridhai usaha
kita semua.

Penyusun

Nurqaulan Karima Gustari

iii
 DAFTAR ISI

HALAMAN JUDUL
HALAMAN PERSETUJUAN .................................................................... ii
KATA PENGANTAR .................................................................................. iii
DAFTAR ISI ............................................................................................... iv
DAFTAR TABEL ........................................................................................ v
DAFTAR GAMBAR .................................................................................... vi

BAB I PENDAHULUAN ....................................................................... 1

A. Latar Belakang ......................................................................... 1
B. Rumusan Masalah .................................................................... 5
C. Tujuan Penelitian ..................................................................... 5
D. Manfaat Penelitian .................................................................... 5

BAB II TINJAUAN PUSTAKA .............................................................. 7

A. Remaja ...................................................................................... 8
B. Obesitas ..................................................................................... 8
1. Remaja Obesitas ................................................................. 8
2. Etiologi Obesitas ................................................................. 10
3. Dampak Remaja Obesitas ................................................... 11
C. Psikososial ................................................................................ 12
1. Gambaran Pengaruh Obesitas terhadap Psikososial
Remaja ................................................................................ 14
D. Meta Analisis ............................................................................ 17
E. Kerangka Teori ......................................................................... 22

BAB III METODE PENELITIAN ........................................................... 23

A. Desain Penelitian ...................................................................... 23
B. Keragka Konsep ........................................................................ 23
C. Variabel Penelitian .................................................................... 23
D. Hipotesis ................................................................................... 23
E. Definisi Operasional ................................................................. 24
F. Pengumpulan Data .................................................................... 24
1. Sumber Data ....................................................................... 24
2. Stratgi Penelitian ................................................................. 25
a. PICOTS ......................................................................... 25
b. Kata Kunci .................................................................... 26
c. Kriteria Inklusi dan Eksklusi ........................................ 27
d. PRISMA (Seleksi Studi) ............................................... 27
G. Penilaian Kualitas Meta Analisis .............................................. 30
H. Analisis Data ............................................................................. 30
I. Uji Bias Publikasi ...................................................................... 31
J. Etika Penelitian ......................................................................... 32

DAFTAR PUSTAKA ................................................................................... 34

iv
 DAFTAR TABEL

Tabel 3.1 Definisi Operasional .................................................................... 24

Tabel 3.2 PICOTS Framework Meta Analisis : Pengaruh Obesitas
Terhadap Psikososial Remaja...................................................... 26
Tabel 3.3 Kata Kunci Pencarian Pencarian Artikel atau Jurnal .................. 26

v
 DAFTAR GAMBAR

Gambar 2.1 Kerangka Teori ......................................................................... 22

Gambar 3.1 Kerangka Konsep ...................................................................... 23
Gambar 3.2 Bagan PRISMA ........................................................................ 29

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 BAB I

PENDAHULUAN

A. Latar Belakang

Masa remaja ialah masa pertumbuhan dan perkembangan yang cepat,

baik secara fisik, psikologis dan intelektual (Kharistik A et al., 2018). Masa

remaja adalah tahap perkemangan yang penting yang didefinisikan dengan

menavigasi situasi sosial yang sulit dan memperkuat identitas selama transisi

orang muda ke masa dewasa yang aru muncul. Masa remaja juga merupakan

periode pertumuhan yang cepat - segera setelah tahun pertama kehidupan -

dan dengan demikian keutuhan nutrisi meningkat secara substansial (Ruiz et

al., 2020).

Obesitas merupakan suatu keadaan status gizi seseorang sebagai akibat

dari ketidakseimbangan asupan dan keluaran energi di dalam tubuh dalam

jangka waktu yang lama, sehingga mengakibatkan penumpukan lemak yang

berlebihan (Noer et al., 2018). Obesitas atau berat badan berlebih termasuk

salah satu masalah kesehatan di seluruh dunia. World Health Organization

(WHO) menyatakan obesitas atau berat badan berlebih merupakan epidemi

global. Obesitas atau berat badan berlebih adalah salah satu ancamman bagi

kesehatan warga/masyarakat yang bekembang pesat di sejumlah Negara di

dunia (Kharistik A et al., 2018).

Obesitas adalah masalah kesehatan yang sering kali terjadi pada remaja

yang tinggal di Negara berkembang (Utami et al., 2018). Obesitas pada

remaja merupakan penyakit kompleks yang mencakup masalah medis,

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psikologis dan sosial budaya. Obesitas pada anak-anak dan remaja yang

dianggap sebagai masalah kesehatan masyarakat utama di abad ke-21 telah

mencapai kecepatan pandemi (Andrie et al., 2021b).

Tingginya prevalensi obesitas di kalangan remaja merupakan salah satu

masalah kesehatan masyarakat yang paling serius di negara maju dan

berkembang. Sebagian besar anak-anak yang kelebihan berat badan atau

obesitas tinggal di negara berkembang, di mana tingkat kenaikannya 30%

lebih tinggi daripada di negara-negara yang lebih maju. Selama 40 tahun

terakhir, jumlah anak dan remaja obesitas (5-19 tahun) telah meningkat dari

11 juta pada tahun 1975 menjadi 12 juta pada tahun 2016. Jika tren ini terus

berlanjut, pada tahun 2022, akan ada lebih banyak anak. remaja lebih gemuk

di dunia daripada anak-anak dengan berat badan rata-rata atau sangat kurus

(Flores et al., 2019). Data Riset Kesehatan Dasar (Riskesdas) 2013

menunjukkan bahwa prevalensi remaja gemuk usia 13-15 tahun meningkat

dari 2,5% pada tahun 2010 menjadi 10,8% pada tahun 2013 yang terdiri dari

8,3% berat badan lebih dan 2,5% obesitas. Riskesdas 2018, prevalensi

kegemukan dan obesitas pada usia 13-15 tahun sebesar 16,0% dan usia 16-18

tahun sebesar 13,5%. Jumlah remaja yang mengalami obesitas di Indonesia

meningkat setiap tahunnya (Kementerian Kesehatan Republik Indonesia,

2018).

Obesitas pada masa remaja meningkatkan risiko obesitas pada di masa

dewasa, dan dapat menyebabkan berbagai gangguan kardiovaskular dan

metabolisme. Remaja obesitas rentan terhadap prasangka sosial, dan

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diskriminasi, tidak hanya dari masyarakat umum tetapi juga dari profesional

medis, dan mungkin ragu untuk mencari perawatan medis (Kharistik A et al.,

2018). Masalah dan gangguan psikososial dapat disebabkan oleh efek stigma.

Stigma tentang obesitas dapat menyebabkan remaja obesitas tidak puas

dengan citra tubuhnya dan memiliki harga diri yang lebih rendah

dibandingkan remaja dengan berat badan normal (Utami et al., 2018).

Faktor psikososial telah sangat terkait dengan obesitas pada remaja. Hal

ini ditandai dengan fakta bahwa remaja obesitas lebih sensitif terhadap saraf

kelaparan eksternal seperti rasa bau makanan dan diet. Orang gemuk

cenderung makan saat mereka mau, dan tidak dengan perut kosong. Remaja

obesitas menunjukkan gejala psikososial negatif seperti depresi, bulimia,

diskriminasi sosial, penurunan harga diri dan kepuasan diri, sehingga

mengurangi kualitas hidup mereka. Efek psikologis akan mencegah

keberhasilan penurunan berat badan pada remaja obesitas. Studi menunjukkan

bahwa remaja obesitas tidak mematuhi terapi nutrisi karena perilaku diet

emosional mereka (Noer et al., 2018).

Hasil penelitian Utami et al. (2018) menunjukkan bahwa remaja putri

obesitas memiliki resiko tinggi mengalami gangguan psikososial 6,395 kali

daripada remaja putri dengan status gizi normal, dikarenakan remaja dengan

obesitas banyak mendapat perundungan. Penelitian Noer et al. (2018) Hasil

wawancara rinci dengan masalah psikososial pada lima subjek obesitas

menunjukkan bahwa subjek menderita stres karena rasa bersalah dan

"dibully" atau diejek oleh teman. Merasa gemuk adalah salah satu gambaran

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negatif masa remaja yang berhubungan dengan stres psikologis. Penelitian

telah menunjukkan bahwa citra tubuh negatif dan harga diri yang rendah

memediasi hubungan antara obesitas dan intimidasi. Obesitas remaja tidak

hanya mempengaruhi aspek psikososial obesitas remaja, khususnya gejala

rendah diri, depresi, dan kecemasan, tetapi juga harga diri rendah dan

pengucilan sosial, stigma, yang mempengaruhi kualitas hidup.

Meta-analisis merupakan suatu metode yang melakukan analisis secara

mendalam terhadap suatu point dari beberapa penelitian substantial yang

dijadikan satu sehingga menyerupai sebuah penelitian besar dengan

menggunakan analisis statistik. Meta-analisis memungkinkan kita untuk

secara kuantitatif menggabungkan berbagai jenis hasil studi. Meta-analisis

juga dapat menggambarkan hubungan antar studi dengan baik, yang pada

gilirannya dapat mengoreksi perbedaan hasil antar studi. Lebih jauh, sifat

meta-analisis yang lebih objektif daripada tinjauan naratif memungkinkan

meta-analisis untuk lebih fokus pada data, daripada hasil studi yang berbeda.

Selain itu, meta-analisis lebih mudah dilakukan karena dilakukan secara

kuantitatif dan berfokus pada ukuran efek. Meta-analisis memungkinkan hasil

studi yang ereda untuk digaungkan dan memperhitungkan ukuran sampel

relatif dan ukuran efek. Hasil tinjauan ini justru didasarkan pada cakupan

analisis ini yang sangat luas dan terfokus. Meta-analisis juga memerikan

jawaan atas pertanyaan yang dipereutkan oleh inkonsistensi dalam

kesimpulan dari studi serupa yang berbeda. (Retnawati et al., 2018).

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 Masih sangat sedikit penelitian dengan studi meta analisis yang

membahas tentang pengaruh obesitas terhadap psikososial remaja. Maka

penulis tertarik untuk melakukan penelitian dengan judul “Meta Analisis :

Pengaruh Obesitas Terhadap Psikososial Remaja”

B. Rumusan Masalah

Apakah ada Pengaruh Obesitas terhadap kejadian psikososial anak

remaja?

C. Tujuan Penelitian

a. Tujuan Umum

Menganalisis Pengaruh obesitas terhadap psikososial anak remaja

b. Tujuan Khusus

a. Mengidentifikasi besar masalah kejadian remaja obesitas

b. Mengetahui Gambaran Psikososial Remaja

c. Mengetahui pengaruh obesitas terhadap psikososial remaja

D. Manfaat Penelitian

a. Bagi Peneliti

Memberikan pengalaman dan manfaat untuk menambah ilmu

pengetahuan dalam penelitian di bidang gizi dan psikologi.

b. Bagi Masyarakat

Bagi Masyarakat Penelitian ini dapat memberikan informasi kepada

masyarakat khususnya Remaja, tentang dampak dari obesitas terhadap

psikososial remaja. Masyarakat juga mendapatkan informasi tentang

seberapa berpengaruh obesitas terhadap psikososial. Sehingga dapat

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 menjadi acuan bagi masyarakat dalam upaya menurunkan prevalensi

remaja obesitas dengan gangguan psikososial.

c. Bagi Institusi

Bagi Poltekkes Kemenkes Bengkulu Hasil penelitian ini dapat

menjadi bahan ajar kesehatan masyarakat tentang Pengaruh Obesitas

Terhadap Psikososial Remaja. Hasil penelitian juga dapat meningkatkan

jumlah publikasi yang berkontribusi bagi peneliti dan institusi perguruan

tinggi.

d. Bagi Peneliti Lain

Hasil penelitian ini diharapkan dapat dijadikan dasar bagi peneliti

selanjutnya untuk melakukan penelitian yang lebih mendalam tentang

Pengaruh Obesitas Terhadap Psikososial Remaja.

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 BAB II

TINJAUAN PUSTAKA

A. Remaja

Masa remaja merupakan masa huungan atau transisi antara masa kanak-

kanak dan masa dewasa. dimana pada masa ini terjadi peruahan-peruahan

esar dan esensial yang erkaitan dengan pematangan fungsi mental dan fisik

terutama fungsi seksual. Masa remaja meliputi masa remaja awal (10-14

tahun) masa remaja pertengahan (14 - 17 tahun) dan masa remaja akhir (17 -

19 tahun). Remaja sering diharapkan untuk berperilaku seperti orang dewasa

bahkan jika mereka belum siap secara psikologis. Pada saat ini konflik sering

muncul karena anak di awah umur menginginkan kebebasan untuk mengikuti

teman dekat mereka untuk mengetahui identitas mereka. Di sisi lain mereka

masih bergantung pada orang tua mereka (Imelda et al., 2016).

Pada tahap perkembangan ini, remaja sering menghadapi masalah

dalam hidup, antara lain: Kesalahan dalam peran dan tanggung jawabnya,

sering merasa disalahkan, atau diperlakukan, ketidakadilan, ketidaktertarikan,

kesulitan memahami perasaan sendiri, kesulitan mengambil keputusan. Pada

masa remaja, hubungan sosial sangat penting bagi remaja. Remaja mulai

memperluas hubungan sosialnya dengan teman sebayanya. Remaja sering

keluar bersama teman sebayanya, karena dapat dimaklumi bahwa pengaruh

mereka terhadap sikap, minat, penampilan dan perilaku lebih besar daripada

pengaruh orang tuanya. Pada usia ini, seorang remaja seringkali sangat labil,

mudah terombang-ambing oleh bujukan, dan meskipun dia ingin mencoba

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 sesuatu yang baru, dia mungkin tidak tahu apakah itu bagus atau tidak karena

dia ingin tampil menarik dan tampil dengan gaya yang berbeda (Imelda et al.,

2016).

B. Obesitas

Obesitas menggambarkan akumulasi lemak dalam sel-sel lemak yang

dapat terjadi jika kalori yang dikonsumsi dari makanan melebihi kebutuhan

metabolisme tubuh untuk pertumbuhan, perkembangan dan aktivitas fisik.

Obesitas pada tahun-tahun pertama kehidupan dapat meningkatkan risiko

obesitas di masa dewasa dan menyebabkan peningkatan morbiditas dan

mortalitas di masa dewasa (Utami et al., 2018). Obesitas adalah penyakit

kronis dengan berbagai penyebab, termasuk faktor risiko biologis, status

sosial ekonomi, literasi kesehatan, dan berbagai pengaruh lingkungan (Ruiz et

al., 2020).

Obesitas merupakan penyakit kompleks yang disebabkan oleh faktor

kerentanan genetik, peningkatan konsumsi makanan berenergi tinggi, dan

penurunan aktivitas fisik pada masyarakat modern. Obesitas mengacu pada

kelebihan lemak tubuh. Obesitas mempengaruhi banyak sistem organ,

dikaitkan dengan komorbiditas medis dan psikologis, serta stigma dan

tekanan sosial (Fitri & Rakhmawatie, 2012).

1. Remaja Obesitas

Obesitas pada remaja merupakan hasil pengukuran Indeks Massa

Tubuh (IMT) yang diperoleh dari berat badan dibagi kuadrat tinggi badan,

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dan dikategorikan obesitas jika Indeks Massa Tubuh ≥25 kg/m2 (Fitri &

Rakhmawatie, 2012).

Obesitas pada anak-anak dan remaja dianggap sebagai masalah

kesehatan masyarakat utama abad ke-21, yang telah menjadi epidemi.

Selama dekade terakhir, prevalensi penyakit ini meningkat, dengan

jumlah anak yang kelebihan berat badan dan obesitas meningkat secara

dramatis dari 4% pada tahun 1975 menjadi 18% pada tahun 2016. Pada

tahun 2016, diperkirakan 340 juta anak dan remaja berusia 5 hingga 19

tahun secara global didiagnosis sebagai kelebihan berat badan. atau

obesitas. Anak laki-laki cenderung lebih sering kelebihan berat badan atau

obesitas daripada anak perempuan; pada anak-anak dan remaja berusia 5

hingga 17 tahun, 22,9% anak laki-laki dan 21,4% anak perempuan

mengalami kelebihan berat badan atau obesitas (Andrie et al., 2021b).

Tingginya prevalensi obesitas di kalangan remaja merupakan salah

satu masalah kesehatan masyarakat yang paling serius di negara maju dan

berkembang. Sebagian besar anak-anak yang kelebihan berat badan atau

obesitas tinggal di negara berkembang, Di mana tingkat kenaikannya 30%

lebih tinggi daripada di negara-negara yang lebih maju. Selama 40 tahun

terakhir, jumlah anak dan remaja obesitas (5-19 tahun) telah meningkat

dari 11 juta pada tahun 1975 menjadi 12 juta pada tahun 2016. Jika tren

ini terus berlanjut, pada tahun 2022, akan ada lebih banyak anak. remaja

lebih gemuk di dunia daripada anak-anak dengan berat badan rata-rata

atau sangat kurus (Flores et al., 2019). Data Riset Kesehatan Dasar

9
 (Riskesdas) 2013 menunjukkan bahwa prevalensi remaja gemuk usia 13-

15 tahun meningkat dari 2,5% pada tahun 2010 menjadi 10,8% pada

tahun 2013 yang terdiri dari 8,3% berat badan lebih dan 2,5% obesitas.

Riskesdas 2018, prevalensi kegemukan dan obesitas pada usia 13-15

tahun sebesar 16,0% dan usia 16-18 tahun sebesar 13,5%. Jumlah remaja

yang mengalami obesitas di Indonesia meningkat setiap tahunnya

(Kementerian Kesehatan Republik Indonesia, 2018).

2. Etiologi Obesitas

Akar penyebab obesitas adalah multifaktorial. Faktor genetik dan

lingkungan termasuk beberapa infeksi, gaya hidup, dan perilaku makan.

Masalah psikososial juga dapat berkontribusi pada perkembangan

obesitas. Selama stres emosional atau fisik, sumbu hipotalamus-hipofisis-

adrenal (HPA) diaktifkan, sementara dopamin mungkin juga terlibat.

Stres dikaitkan dengan perubahan perilaku makan; Sekitar 40% orang

meningkatkan asupan makanan mereka selama masa stres. Selama masa

stres, makanan yang sangat lezat, seringkali tinggi gula dan lemak,

dimakan tanpa memandang rasa lapar (Andrie et al., 2021).

Remaja obesitas lebih cenderung mengkonsumsi makanan cepat

saji dan jajanan di sekolah dibandingkan remaja non-obesitas. Selain itu,

di Uni Emirat Arab (UEA), makanan cepat saji ditemukan memiliki

hubungan yang signifikan dengan obesitas pada wanita. Selain itu, risiko

obesitas pada remaja laki-laki akibat mengonsumsi makanan cepat saji di

rumah lebih tinggi dibandingkan pada remaja putri. Selain beberapa

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 faktor penyebab langsung, faktor lingkungan dan genetik juga berperan

dalam timbulnya obesitas pada seseorang. Lingkungan akan menentukan

jumlah makanan yang tersedia. Lingkungan rumah berpengaruh terhadap

kejadian obesitas melalui ketersediaan makanan dan aktivitas fisik.

Semakin buruk asupan makanan dan aktivitas fisik, semakin tinggi risiko

obesitas (Fajriyah et al., 2020).

3. Dampak Remaja Obesitas

Beberapa efek dapat dikaitkan dengan obesitas, dan tindakan

pencegahan perlu dilakukan dengan melihat faktor-faktor yang

mempengaruhinya. Menurut beberapa penelitian, faktor yang

mempengaruhi obesitas antara lain pola makan, ngemil, dan aktivitas

fisik. Selain itu, variabel tempat tinggal dapat mempengaruhi obesitas

(Fajriyah et al., 2020).

Obesitas pada remaja berisiko tinggi menjadi obesitas pada masa

dewasa dan berpotensi menjadi penyebab berbagai penyakit

kardiovaskular serta metabolik. Data WHO, lebih dari 1.4 miliar orang

dewasa memiliki berat badan berlebih dan 2.8 juta orang dewasa

meninggal tiap tahun karena obesitas dan berat berlebih yang

menyebabkan munculnya berbagai penyakit kronis seperti diabetes dan

penyakit jantung. Obesitas juga telah dikaitkan dengan spektrum luas

lainnya, selain diabetes tipe 2, penyakit degeneratif, termasuk kelainan

metabolik dan bentuk kanker tertentu. Dilaporkan sebesar 80%

menyebabkan diabetes tipe 2, 70% penyakit kardiovaskular, dan 42

11
 persen menyebabkan kanker payudara dan kolon. Obesitas adalah faktor

utama di balik 30 gangguan kandung empedu, yang menyebabkan

pembedahan dan 26 insiden tekanan darah tinggi (Kharistik A et al.,

2018).

Kelebihan berat badan meningkatkan risiko masalah kesehatan

mental dan somatik, harga diri rendah, dan dapat menyebabkan

intimidasi, terutama pada anak-anak dan remaja. Akibatnya, hal ini dapat

menyebabkan kinerja akademik yang buruk, keluhan terkait mental dan

sekolah (Brooks et al., 2021).

Permasalahan yang dapat terjadi pada remaja obesitas selain

permasalahan kesehatan adalah psikososial. Gangguan atau permasalahan

psikososial dapat disebabkan karena pengaruh dari stigma. Stigma

obesitas dapat menyebabkan remaja obesitas memiliki ketidakpuasan

terhadap citra tubuhnya dan mempunyai harga diri yang lebih rendah

daripada remaja dengan berat badan normal. Remaja yang kelebihan berat

badan dan obesitas yang diintimidasi karena berat badan mereka berada

pada peningkatan risiko kesehatan psikologis yang buruk, seperti harga

diri rendah, harga diri rendah, ketidakpuasan tubuh, dan depresi (Utami et

al., 2018).

C. Psikososial

Gangguan psikologis seperti depresi, kecemasan dan stres dianggap

sebagai salah satu faktor risiko obesitas baik di masa kanak-kanak maupun

setelah dewasa. Berbagai jenis stresor dapat menyebabkan depresi,

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kecemasan, dan stres pada anak usia sekolah. Hal ini dapat berupa stressor

dari keluarga, lingkungan sekolah, dapat berupa stressor yang berhubungan

dengan kegiatan sekolah, guru dan teman-teman disekolah. Perempuan lebih

mungkin mengalami depresi daripada laki-laki, mungkin karena sejumlah

faktor, termasuk bahwa perempuan kurang asertif dan cenderung memiliki

skor kepemimpinan yang lebih rendah daripada anak laki-laki dan

perempuan.cenderung lebih adaptif terhadap ruminansia daripada anak laki-

laki, yaitu anak perempuan biasanya lebih perhatian tentang gejala depresi

(Masdar et al., 2016).

Gangguan psikososial adalah setiap perubahan dalam kehidupan

individu baik yang bersifat psikologis ataupun sosial yang mempunyai

pengaruh timbal balik dan dianggap berpotensi cukup besar sebagai faktor

penyebab terjadinya gangguan kesehatan jiwa atau gangguan kesehatan

secara nyata, atau sebaliknya masalah kesehatan jiwa yang berdampak pada

lingkungan sosial. Gangguan psikososial yang sering terjadi pada remaja

adalah adanya ketidakpuasan citra tubuh, rendahnya harga diri, terjadinya

perundungan, dan depresi (Utami et al., 2018).

Secara psikologis, depresi merupakan respon emosional yang ditandai

dengan keputusasaan, penurunan motivasi, harga diri rendah, proses berpikir

melambat, keterbelakangan psikomotor, dan gangguan tidur. Kegemukan dan

obesitas serta persepsinya dapat meningkatkan stres psikologis.Sebagian

masyarakat masih percaya bahwa kurus adalah bentuk kecantikan, kecantikan

adalah penerimaan masyarakat dan faktor sosial budaya. Hal ini

13
meningkatkan ketidakpuasan tubuh dan menurunkan harga diri, yang

merupakan faktor risiko depresi (Kharistik A et al., 2018).

Hubungan antara kekurangan berat badan atau keleihan berat badan dan

keluhan psikiatri (PSC) pada remaja telah dipelajari dengan buruk. PSC

mengacu pada gejala psikologis dan fisik yang dialami oleh orang dengan

atau tanpa diagnosis pasti seperti kecemasan, depresi, sakit kepala, dan sakit

perut. CSP dianggap sebagai indikator kesehatan yang buruk pada anak-anak

dan remaja. Misalnya PSC sebelumnya telah dikaitkan dengan stres kesehatan

yang lebih buruk dan gejala kesehatan mental. Sebuah penelitian di Swedia

berdasarkan survei Health Behavior in School Children (HBSC) menemukan

peningkatan prevalensi masalah kesehatan mental di kalangan remaja yang

lebih tua terutama di kalangan remaja yang lebih tua adalah anak perempuan.

Telah menunjukkan bahwa anak-anak dan remaja yang kelebihan berat badan

dan obesitas dan mereka yang menganggap diri mereka kelebihan berat badan

lebih cenderung memiliki masalah kesehatan daripada mereka yang memiliki

berat badan normal (Brooks et al., 2021).

1. Gambaran Dan Pengaruh Obesitas Terhadap Psikososial Remaja

Ada tiga kemungkinan jalur yang dapat menjelaskan gangguan

psikososial komorbiditas: obesitas dapat mempengaruhi orang untuk

depresi, depresi dapat mempengaruhi orang untuk obesitas, atau faktor

ketiga dapat mempengaruhi orang untuk kedua kondisi ini. Obesitas dapat

menyebabkan depresi karena stigma berat badan, harga diri rendah

dan/atau gangguan fungsional (penurunan mobilitas dan kemampuan

14
untuk berpartisipasi dalam aktivitas). Depresi dapat menyebabkan obesitas

secara langsung melalui perkembangan gejala depresi (misalnya, nafsu

makan meningkat, kurang tidur, lesu sehingga konsumsi kalori menurun

dan/atau kebutuhan energi berkurang), dan memasak makanan sehat, efek

samping antidepresan, atau mencoba mementingkan diri sendiri. obati

depresi dengan makanan tidak sehat (Marmorstein et al., 2014).

Faktor psikososial telah sangat terkait dengan obesitas pada remaja.

Hal ini ditandai dengan fakta bahwa remaja obesitas lebih sensitif terhadap

saraf kelaparan eksternal seperti rasa bau makanan dan diet. Orang gemuk

cenderung makan saat mereka mau, dan tidak dengan perut kosong.

Remaja obesitas menunjukkan gejala psikososial negatif seperti depresi,

bulimia, diskriminasi sosial, penurunan harga diri dan kepuasan diri,

sehingga mengurangi kualitas hidup mereka. Efek psikologis akan

mencegah keberhasilan penurunan berat badan pada remaja obesitas. Studi

menunjukkan bahwa remaja obesitas tidak mematuhi terapi nutrisi karena

perilaku diet emosional mereka (Noer et al., 2018).

Remaja obes mudah mengalami gangguan psikososial karena

memiliki rasa percaya diri yang rendah, persepsi diriyang negatif, dan rasa

rendah diri, serta menjadi bahan ejekan teman-temannya. Gangguan

psikososial pada anak obes dapat disebabkan oleh dua faktor, yaitu faktor

internal dan faktor eksternal. Faktor internal merupakan faktor yang

berasal dari anak itu sendiri, yaitu keinginan untuk menguruskan badan

dan merasa berbeda dengan anak lain sehingga anak obes mempunyai rasa

15
percaya diri yang rendah dan mudah mengalami depresi. Faktor eksternal

merupakan faktor yang berasal dari lingkungan yang memberikan

“stigma” pada anak obes yang dianggap sebagai anak yang malas,

bodoh,dan lamban (Pujiastuti et al., 2016).

Hubungan yang merugikan antara kelebihan berat badan/obesitas

atau kekurangan berat badan dan beberapa keluhan terkait sekolah dapat

dijelaskan oleh ketidaknyamanan psikologis dan kesejahteraan umum yang

lebih buruk. Masalah psikologis seperti kecemasan, kegugupan, dan

tekanan mental dapat dikaitkan dengan peningkatan ketegangan otot, yang

dapat menyebabkan rasa sakit, terutama di leher dan bahu. Keluhan

psikosomatik subjektif tidak selalu terkait dengan diagnosis atau penyakit

yang ditentukan, tetapi mungkin mencerminkan ketidaknyamanan

psikologis dan gangguan kesejahteraan global di masa kanak-kanak

(Brooks et al., 2021).

Lingkungan merupakan keseluruhan fenomena fisik atau sosial

yang memengaruhi atau dipengaruhi perkembangan remaja, meliputi

lingkungan keluarga, sekolah, teman sebaya, dan masyarakat. Faktor

keluarga yang memengaruhi perkembangan anak/remaja, yaitu fungsi

keluarga, pola hubungan orangtua–anak, serta kelas sosial, dan status

ekonomi (Pujiastuti et al., 2016).

Arah paparan obesitas mengakibatkan depresi dapat dilihat secara

biologis dan psikologis. Secara biologis, obesitas atau berat berlebih

merupakan suatu keadaan peradangan, karena penambahan berat badan

16
 telah terbukti mengaktifkan jalur inflamasi dalam tubuh. Sedangkan

peradangan itu sendiri, berperan dalam terjadinya depresi. Sumbu

hipotalamushipofisi-adrenal (sumbu HPA) dianggap berperan. Obesitas

melibatkan disregulasi sumbu HPA dan diketahui disregulasi sumbu HPA

terlibat dalam terjadinya depresi. Selain mekanisme biologis, kejadian

depresi yang disebabkan karena obesitas dan berat berlebih pun dapat

dijelaskan secara mekanisme psikologis. Depresi adalah respon emosional

dengan ciri keputus-asaan, motivasi berkurang, penghargaan terhadap diri

rendah, proses berpikir yang lambat, retardasi psikomotor serta gangguan-

gangguan makan dan tidur. Kelebihan berat badan hingga obesitas dan

persepsinya dapat meningkatkan tekanan psikologis (Kharistik A et al.,

2018).

D. Meta Analisis

1. Pengertian

Dalam literatur kedokteran dikenal artikel yang berupaya

menggabungkan hasil berbagai studi orisinal yang independen, yang

dikenal dengan nama integrative literature; yang paling lama dikenal

adalah tinjauan pustaka (literature review, dikenal pula dengan nama

review article, overview, atau state of the art review). Artikel jenis ini

bersifat naratif dan tidak dilakukan dengan sistematis, yang artinya

(Nindrea, 2016) :

a. Penelusuran dan pemilihan artikel yang hendak digabungkan tidak

dilakukan dengan kriteria yang ditetapkan sebelumnya

17
b. Kurang dilakukan telaah kritis dan evaluasi sistematis terhadap kualitas

artikel. Akibatnya overview ini terancam bias; dapat saja penulis (sadar

atau tidak) memilih artikel yang mendukung pendapatnya dan tidak

menyertakan sumber lain yang bertentangan (Nindrea, 2016).

Bentuk lain adalah tinjauan pustaka yang dibuat secara sistematis

dan terencana. Dari awal telah direncanakan dengan jelas jenis artikel yang

akan digabung, teknik penelusuran pustaka, serta penelaahan kualitas

setiap artikel. Bila dalam tinjauan tersebut tidak digunakan analisis

statistika secara formal, tinjauan pustaka itu disebut sebagai systematic

review, sedangkan bila dalam analisisnya digunakan metode statistika

formal, jenis review tersebut dinamakan meta-analisis. Ketiga bentuk

artikel tersebut secara umum disebut sebagai review article; review article

yang disusun secara sistematis disebut systematic review, dan systematic

review yang memakai analisis statistika formal disebut sebagai meta-

analisis (Nindrea, 2016)

Meta-analisis ialah suatu teknik statistika untuk menggabungkan

hasil 2 atau lebih penelitian sejenis sehingga diperoleh paduan data secara

kuantitatif. Saat ini meta-analisis paling banyak digunakan untuk uji klinis.

Hal ini dapat dimengerti, karena uji klinis desainnya lebih baku dan

memberikan bukti hubungan kausal yang paling kuat. Meta-analisis juga

dapat dilakukan terhadap berbagai studi observasional, untuk

menghasilkan kesimpulan dari hasil penggabungan hasil penelitian

tersebut (Nindrea, 2016).

18
 Effect size, yakni perbedaan kejadian efek antara kelompok

eksperimental dan kelompok kontrol dalam meta-analisis merupakan

gabungan effect size masing-masing studi yang dilakukan dengan teknik

statistika tertentu. Karena pada umumnya pembuat meta-analisis tidak

memiliki data dasar penelitian, maka praktis dimensi effect size yang

digabungkan dalam meta-analisis sama dengan yang dilaporkan dalam

artikel yang digabungkan. Skala variabel efek pada meta-analisis dalam

literatur kedokteran dapat berskala nominal, numerik, atau ordinal

(Nindrea, 2016)

2. Tujuan Meta Analisis

Tujuan meta-analisis pada umumnya tidak berbeda dengan jenis

penelitian klinis lainnya, yaitu:

a. Untuk memperoleh estimasi effect size, yaitu kekuatan hubungan

ataupun besarnya perbedaan antar-variabel

b. Melakukan inferensi dari data dalam sampel ke populasi, baik

dengan uji hipotesis (nilai p) maupun estimasi (interval

kepercayaan)

c. Melakukan kontrol terhadap variabel yang potensial bersifat

sebagai perancu (confounding) agar tidak mengganggu

kemaknaan statistik dari hubungan atau perbedaan (Nindrea,

2016).

19
3. Kelebihan dan Keterbatasan Meta Analisis

Setiap desain penelitian tentu implisit mengandung kelebihan dan

kekurangan. Kualitas meta-analisis tergantung, untuk sebagian besar, pada

kualitas studi yang dipadukan. Paduan banyak penelitian yang tidak

adekuat sama buruknya dengan masing-masing studi yang tidak adekuat

tersebut. Maka studi yang diikutsertakan dalam meta-analisis harus

berkualitas baik. Berikut beberapa kelebihan dan keterbatasan meta-

analisis (Nindrea, 2016) :

a. Kelebihan

1. Meta-analisis mendorong pemikiran sistematis tentang metode,

kategorisasi, populasi, intervensi, outcome dan cara untuk

memadukan berbagai bukti. Metode ini menawarkan mekanisme

untuk estimasi besarnya efek dalam pengertian statistika (rasio odds

atau risiko relatif) dan kemaknaannya.

2. Penggabungan data dari berbagai studi akan meningkatkan

kemampuan generalisasi dan power statistika, sehingga dampak

suatu prosedur dapat dinilai lebih lengkap. Namun harus diingat

bahwa peningkatan power akan memperbaiki nilai p sehingga

perbedaan yang kecil sekali pun dapat menjadi bermakna secara

statistika; padahal perbedaan tersebut belum tentu penting secara

klinis, bagi klinikus yang lebih penting adalah menilai kemaknaan

klinis.

20
 3. Jumlah individu yang bertambah banyak dalam meta-analisis

memberi kesempatan untuk interpretasi data tentang keamanan

ataupun bahaya dengan tingkat kepercayaan yang lebih besar.

4. Jumlah subyek yang besar juga memungkinkan untuk dilakukan

analisis terhadap sub-grup yang tidak dapat dilakukan pada

penelitian aslinya, misalnya efek intervensi pada lelaki atau

perempuan secara terpisah, atau pada kelompok usia tertentu.

5. Hasil meta-analisis dapat memberi petunjuk penelitian lebih lanjut,

termasuk besar sampel yang diperlukan.

b. Keterbatasan

1. Karena masih dalam taraf pengembangan, masalah metodologi

menjadi salah satu kekurangan yang harus diperhatikan bila kita

membaca artikel tentang meta-analisis. Hal-hal yang masih

merupakan kontroversi dapat dianggap juga merupakan

keterbatasan atau kekurangan meta-analisis, termasuk kesesuaian

penggabungan data berbagai studi, pemakaian metode statistik,

variabilitas antar studi, pengembangan model untuk mengukur

variabilitas, dan peran penilaian kualitas studi.

2. Bias publikasi merupakan masalah yang mengancam pada meta-

analisis. Meta-analisis yang hanya mencakup studi yang dipublikasi

mungkin tidak menggambarkan keadaan yang sebenarnya, karena

banyak studi yang hasilnya negatif tidak dipublikasi atau tidak

diusulkan untuk publikasi. Sebaliknya apabila disertakan data yang

21
 tidak dipublikasi, harus diyakinkan bahwa sumber datanya tidak

mempunyai conflict of interest, dan sumber data yang tidak

dipublikasi tersebut harus ditelusur dengan teliti.

3. Perbedaan mendasar antara meta-analisis dengan jenis penelitian

lain ialah bahwa pada meta-analisis data telah dikumpulkan, pilihan

peneliti terbatas dalam menyertakan atau menyingkirkan studi-studi

yang ada. Dengan demikian, besar sampel dalam meta-analisis

sangat dibatasi oleh studi yang relevan yang ada.

4. Dalam meta-analisis, peneliti biasanya harus mengikuti metode

yang dipakai oleh peneliti pertama untuk menilai hasil studi.

Keterbatasan meta-analisis lainnya adalah kelengkapan dan kualitas

data yang tersedia dan metode statistika yang dipakai dalam artikel

asal (Nindrea, 2016)

E. Kerangka Teori

F. Berdasarkan tinjauan pustaka di atas, maka dapat digambarkan kerangka

teori sebagai berikut :

Remaja

Obesitas Psikososial

Gambaran
danPengaruh
Remaja Etiologi Dampak
Obesitas Terhadap
Obesitas Obesitas Remaja
Psikososial Remaja
Obesitas

Gambar 2.1 Kerangka teori

22
 BAB III

METODE PENELITIAN

A. Desain Penelitian

Desain penelitian ini menggunakan metode meta analisis, meta analisis

merupakan bentuk penelitian kuantitatif dengan metode statistic dengan

menggunakan sejumlah data yang cukup banyak dan berasal dari penelitian

sebelumnya. Yang mencoba menggali hasil penelitian di dunia yang terkait

dengan Pengaruh Obesitas Terhadap Psikososial Remaja.

B. Kerangka Konsep

Variabel Independent : Variabel Dependent :

Obesitas Psikososial

Gambar 3.1 Kerangka Konsep

C. Variabel Penelitian

a. Variable bebas : Obesitas

b. Variabel terikat : Psikososial

D. Hipotesis

Hipotesis merupakan perkiraan hasil penelitian. Hal ini bertujuan untuk

memberikan apakah hipotesis diterima atau ditolak. Adapun hipotesis pada

penelitian ini sebagai berikut :

Ha : Ada pengaruh Obesitas Terhadap Psikososial Remaja

H0 : Tidak ada Pengaruh Obesitas Terhadap Psikososial Remaja

23
E. Definisi Operasional

Tabel 3.1 Definisi Operasional

Cara
Variabel Definisi Operasional Alat Ukur Hasil Ukur
Ukur
Suatu keadaan pada remaja
yang memiliki jumlah massa
lemak tubuh tinggi dihitung 1. Obesitas
Jurnal Identi
dengan IMT yaitu dengan cara 2. Tidak
Obesitas hasil fikasi
membagi berat badan (kg) Obesitas
Penelitian jurnal
dengan tinggi badan (meter)
kuadrat dimana hasilnya
>25kg/m2
Perubahan dalam kehidupan Jurnal Identi
Psikosos 1. Ya
individu, baik bersifat hasil fikasi
ial 2. Tidak
psikologis maupun sosial. Penelitian Jurnal

F. Pengumpulan Data

1. Sumber Data

a. Data Base

Data yang digunakan dalam penelitian ini berasal dari hasil-hasil

penelitian yang sudah dilakukan dan dipublikasikan dalam artikel

online nasional dan internasional. Sumber data yang digunakan dari

database online, repositori baik dari Indonesia maupun negara lain yang

menggunakan bahasa Inggris dan atau bahasa Indonesia. Pada

penelitian ini, Jenis sumber kepustakaan yang dapat digunakan adalah

data sekunder yang diperoleh dari hasil-hasil peneliti sebelumnya yang

menggunakan data primer. Dalam melakukan penelitian ini peneliti

melakukan pencarian literatur penelitian yang dipublikasikan di internet

menggunakan kata kunci pada mesin pencari (search engine), seperti :

Google Scholar, PubMed, Crossref.

24
2. Strategi Penelitian

a. PICOTS

Strategi yang digunakan untuk mencari jurnal/artikel dalam

penelitian ini menggunakan strategi PICOTS framework, yang terdiri

dari:

1. Population/problem yaitu populasi atau masalah yang akan di

analisis sesuai dengan tema yang sudah ditentukan dalam Meta

Analisis

2. Intervention yaitu suatu tindakan penatalaksanaan terhadap kasus

perorangan atau masyarakat serta pemaparan tentang

penatalaksanaan studi sesuai dengan yang sudah ditentukan dalam

Meta Analis

3. Comparation yaitu intervensi atau penatalaksanaan lain yang

digunakan sebagai pembanding jika tidak ada bisa menggunakan

kelompok kontrol dalam studi yang terpilih

4. Outcome yaitu hasil atau keluaran yang diperoleh pada studi

terdahulu yang sesuai dengan tema yang sudah ditentukan dalam

Meta Analisis

5. Study design yaitu desain penelitian yang digunakan dalam artikel

yang akan di review.

25
 Tabel 3.2 PICOTS Framework Meta Analisis : Pengaruh
Obesitas Terhada Psikososial Remaja
Kriteria Kriteria Inklusi Kriteria Eksklusi
Population Remaja Yang tidak remaja
Intervention Obesitas Yang tidak obesitas
Comparation Kelompok Kontrol Kelompok Intervensi
Outcomes Menjelaskan ada perbedaan / Tidak membahas
pengaruh / hubungan atau psikososial atau
tidak ada perbedaan / membahas intervensi lain
pengaruh / hubungan
Obesitas terhadap
Psikososial
Stiudy design Case control, Cohort, dan Yang tidak
and Cross Sectional menggunakana desain
publication Case control Cohort,
type dan Cross Sectional
Publication Post-2022 Pre-2011
years
Language English, Indonesian Language other than
English and Indonesian

b. Kata Kunci

Pencarian artikel atau jurnal menggunakan keyword dan

boolenoperator (AND, OR, NOT or AND NOT) yang digunakan

untuk memperluas atau menspesifikasikan pencarian, sehingga

mempermudah dalam penentuan artikel atau jurnal yang digunakan.

Kata kunci dalam meta analisis ini disesuaikan dengan medical

subject heading (MESH) dan terdiri dari sebagai berikut:

Tabel 3.3 Kata Kunci Pencarian Artikel atau Jurnal

Effect Obesity Psycosocial Adolescent
OR OR OR OR
Pengaruh Obesitas Psikososial Remaja
OR OR
Risk Factor Overweight
OR
Relationship

26
c. Kriteria Inklusi dan Eksklusi

1. Kriteria Inklusi

a) Diakses dari database Publish Or Perish (google scholar,

crossref) dan pubmed

b) Subjek adalah remaja dengan obesitas yang mengalami

gangguan psikososial

c) Naskah free dan fultext

d) Bahasa yang digunakan adalah Bahasa Indonesia dan Bahasa

Inggris

e) Tahun Publikasi 2011 – 2022

f) Sesuai dengan topik penelitian

g) Dengan desain penelitian Case control, Cohort, dan Cross

Sectional yang melaporkan OR

2. Kriteria Eksklusi

a) Naskah dalam bentuk abstrak atau tidak dapat diakses fulltext,

berbayar

b) Literatur tidak sesuai topik penelitian

c) Naskah Tidak bisa didownload

d. PRISMA (Seleksi Studi)

Tahap proses pengumpulan data dilakukan dengan alat

pencarian database dans melalui tahapan pencarian literatur. Untuk

proses pengumpulan data itu sendiri dilaukan dengan menggunakan

27
metode PRISMA (Preferre Reporting Items For Dystematic Reviews

And Meta Analysis) yang dibuat dengan aplikasi Revman 5.4.1.

Jurnal penelitian yang akan di analisis adalah jurnal berbahasa

Inggris dan Indonesia, tahun publikasi jurnal yang ditelusuri mulai

dari tahun 2011 hingga 2022. Penelusuran dilakukan dengan

memasukan kata kunci pada database Google Scholar, Pubmed dan

CrossRef pada aplikasi POP (Publish Or Perish). Hasil penelusuran

jurnal dari setiap database digabungkan menjadi satu file di aplikasi

Mendeley. Pada database Google Scholar teridentifikasi sebanyak

2040 jurnal bahasa Inggris dan Indonesia, database Pubmed 52

jurnal, dan di database CrossRef 1000 jurnal. Secara keseluruhan

jumlah yang di dapat sebanyak 3092 jurnal. Selanjutnya jurnal yang

di masukkan ke dalam aplikasi Mendeley dicek duplikasi maka

didapatkan 3052 jurnal yang tidak duplikasi, sedangkan 40 jurnal

terduplikasi. Selanjutnya dieliminasi sebanyak 2785 jurnal karena

judul tidak relevan, berbayar, tidak fulltext dan 267 jurnal lainnya

dapat diterima sesuai kriteria. Di eliminasi kembali sebanyak 242

jurnal yang tidak melaporkan OR, sisa 25 jurnal yang melaporkan

OR. Dari 25 jurnal tersebut terpilih 13 jurnal yang melaporkan OR

dengan studi penelitian Kohort, Cross-Sectional, dan Case Control

sesuai kriteria inklusi dan Picots yang akan di analisis. Berikut bagan

PRISMA yang dibuat menggunakan aplikasi Revman 5.4.1.

28
Gambar 3.2 Bagan PRISMA

29
G. Penilaian Kualitas Meta Analisis

Penilaian kualitas jurnal yang akan di analisis dilakukan dengan

menggunakan Critikal Appraisal Tools berdasarkan design penelitian yang

diambil (kohort, case control, dan cross sectional) yang akan dilampirkan

pada lampiran. Dengan mengambil kesimpulan seperti di bawah jurnal

diterima jika penilaian kualitas jurnal penelitian minimal 50%, jika <50%

maka jurnal ditolak.

H. Analisis Data

Penggabungan hasil dari berbagai penelitian merupakan bagian paling

menentukan dalam Meta Ananalisis. Perlu dicata bahwa penelitian yang

berbeda besar sampel dan kualitasnya tidak bisa diberi perlakuan yang sama.

Penelitian yang memiliki kualitas lebih tinggi mendapat bobot yang lebih

besar.

Analisis dilakukan untuk mendapatkan nilai pooled relative risk

estimate / pooled odds ratio. Analisis data dilakukan dengan metode Mantel-

Haenzel dengan asumsi fixed effect model dan metode DerSimonian-Laird

dengan asumsi random-effect model. Penelitian dengan desain cohort

dianalisis dengan Meta-analisis menggunakan nilai OR.

Menentukan model analisis mana yang digunakan maka hal yang

sebelumnya dilakukan adalah melakukan uji homogenitas varian berdasarkan

hasil Forest Plot dan Funnel Plot. Forest Plot digunakan untuk mengetahui

besarnya variasi dan Punnel Plot digunakan untuk menunjukkan hubungan

30
 antara ukuran efek studi dan ukuran sampel dari berbagai artikel yang

ditelaah.

Penelitian telaah sistematis dilakukan dengan menggunakan perangkat

lunak Review Manager 5.4. Weighted mean differences (WMD) digunakan

untuk menganalisis masing-masing variabel dalam penelitian ini. Interval

kepercayaan (IK) ditetapkan 95% Nilai p kurang dari 0,05 mengindikasikan

data statistik yang signifikan. Cochrane Q test digunakan untuk menilai

heterogenitas data statistik tersebut. Heterogenitas statistik dinilai

menggunakan statistik 12: Jika nilai 12 kurang dari 50%, maka meta analisis

ini menggunakan fixed effects model; Jika nilai 12 sebesar 50% atau lebih,

maka meta analisis ini menggunakan random effects. Hipotesis penelitian

secara keseluruhan diukur dengan z test dan analisis sensitivitas digunakan

untuk menguji heterogenitas statistik. Selanjutnya akan dilakukan uji Bias

Publikasi untuk mengetahui kemungkinan adanya hasil penelitian yang tidak

dipublikasikan semuanya.

I. Uji Bias Publikasi

Pada studi meta analisis harus melakukan analisis penting lainnya yaitu

uji bias publikasi. Tes bias publikasi dilakukan untuk mengantisipasi

kecenderungan bahwa studi yang diterbitkan oleh jurnal hanya studi dengan

hasil yang signifikan sehingga membuat effect size yang diperoleh menjadi

terlalu tinggi dari ukuran yang sebenarnya. Tes bias publikasi dapat dilakukan

dengan menggunakan hasil dari Funnel Plot, Rank Correlation dan

Regression Method, Fail-Safe N, Trim and Fill (Retnawati et al., 2014).

31
 a. Funnel Plot

Funnel Plot dilakukan untuk mendeteksi efek bias publikasi.

b. Rank Correlation dan Regression Method

Hipotesis null keduanya adalah funnel plot tidak asimetris. Jika nilai

p-value two side < α (0,05) maka hipotesis null ditolak atau dengan kata

lain funnel plot simetris (tidak terjadi publication bias).

c. Fail-Safe N

Nilai fail-safe N (FSN) diidentifikasi untuk menghitung probabilitas

bias publikasi. Analisis Nilai fail-safe N (FSN) dilakukan dengan

menggunakan software JASP versi 0.8.4. Jika hasil rata-rata effect size 0

maka tidak ada penelitian yang perlu ditambahkan.

d. Trim and Fill

Nilai trim and fill berkaitan erat dengan funnel plot untuk

mengidentifikasi jumlah studi yang harus dihilangkan dari analisis untuk

menghindari bias publikasi dan adanya interpretasi effect size yang

berlebihan.

J. Etika Penelitian

Etika penelitian yaitu pertimbangan rasional mengenai

kewajibankewajiban moral seorang peneliti atas apa yang dikerjakannya

dalam penelitian, publikasi, dan pengabdiannya kepada masyarakat. Pada

studi penelitian meta analisis peneliti tidak perlu kaji etik karena subjek

penelitiannya adalah artikel penelitian yang sudah dipublikasikan.

32
 Akan tetapi terdapat erdapat beberapa standar etik ketika melakukan

kajian literatur, yaitu :

a. Hindari duplikat publikasi dengan cara menyeleksi artikel yang sama pada

setiap database yang digunakan agar tidak terjadi double counting.

b. Hindari plagiat dengan cara mengutip hasil penelitian orang lain dan

mencantumkan referensi dengan menggunakan ketentuan APA style untuk

mencegah plagiarism.

c. Memastikan data yang dipublikasikan telah diekstraksi secara akurat dan

tidak adanya indikasi untuk mencoba mencondongkan data kea rah

tertentu.

d. Transparansi dengan cara memaparkan segala sesuatu yang terjadi selama

penelitian dengan jelas dan terbuka.

33
 DAFTAR PUSTAKA

Andrie, E. K., Melissourgou, M., Gryparis, A., Vlachopapadopoulou, E.,

Michalacos, S., Renouf, A., Sergentanis, T. N., Bacopoulou, F., Karavanaki,
K., Tsolia, M., & Tsitsika, A. (2021b). Psychosocial factors and obesity in
adolescence: A case-control study. Children, 8(4), 1–11.
https://doi.org/10.3390/children8040308

Brooks, S. J., Feldman, I., Schiöth, H. B., & Titova, O. E. (2021). Important
gender differences in psychosomatic and school-related complaints in
relation to adolescent weight status. Scientific Reports, 11(1), 14147.
https://doi.org/10.1038/s41598-021-93761-0

Fajriyah, A., Handayani, O. W. K., & ... (2020). Obesity Determinants of

Teenagers in Rural Areas. Public Health Perspective …, 1, 9–15.
https://doi.org/p-ISSN 2528-5998

Fitri, D. K., & Rakhmawatie, M. D. (2012). Perbedaan Kejadian Stres Antara

Remaja Putra dan Putri dengan Obesitas di SMA Negeri 1 Wonosari ,
Klaten. Jurnal Kedokteran Muhammadiyah, 1(2), 54–60.

Flores, Y. N., Contreras, Z. A., Ramírez-Palacios, P., Morales, L. S., Edwards, T.

C., Gallegos-Carrillo, K., Salmerón, J., Lang, C. M., Sportiche, N., &
Patrick, D. L. (2019). Increased prevalence of psychosocial, behavioral, and
socio-environmental risk factors among overweight and obese youths in
Mexico and the United States. International Journal of Environmental
Research and Public Health, 16(9). https://doi.org/10.3390/ijerph16091534

Imelda, D.K, F. H., & Widiani, E. (2016). Hubungan obesitas dan hubungan
sosial remaja di SMK Ma’aruf NU 04 P akis Kabupaten Malang. Journal
Nursing News, XI(1), 31–37.

Kementerian Kesehatan Republik Indonesia. (2018). Laporan Nasional Riset

Kesehatan Dasar. Kementerian Kesehatan RI, 1–582.

Kharistik A, Y., Lanti R, Y., & Wekadigunawan, C. S. . (2018). The Psychosocial

Impact of Obesity or Overweight in Adolescents: A Path Analysis Evidence
from Surakarta, Central Java. 77.
https://doi.org/10.26911/mid.icph.2018.01.14

Marmorstein, N. R., Iacono, W. G., & Legrand, L. (2014). Obesity and depression
in adolescence and beyond: reciprocal risks. … Journal of Obesity, 38, 906–
911. https://doi.org/10.1038/ijo.2014.19

Masdar, H., Saputri, P. A., Rosdiana, D., & ... (2016). Depresi, ansietas dan stres

34
 serta hubungannya dengan obesitas pada remaja. Jurnal Gizi Klinik …, 12 no
4, 138–143. https://doi.org/ISSN 2502-4140

Noer, E. R., Kustanti, E. R., & Fitriyanti, A. R. (2018). Perilaku gizi dan faktor
psikososial remaja obes. Jurnal Gizi Indonesia (The Indonesian Journal of
Nutrition), 6(2), 109–113. https://doi.org/10.14710/jgi.6.2.109-113

Pujiastuti, E., Fadlyana, E., & Garna, H. (2016). Perbandingan Masalah

Psikososial pada Remaja Obes dan Gizi Normal Menggunakan Pediatric
Symptom Checklist (PSC)-17. Sari Pediatri, 15(4), 201.
https://doi.org/10.14238/sp15.4.2013.201-6

Retnawati, H., Apino, E., Kartianom, Djidu, H., & Anazifa, R. D. (2018).
Pengantar Meta Analisis.pdf. In Pengantar Analisis Meta (1st ed.). Parama
Publishing.

Ruiz, L. D., Zuelch, M. L., Dimitratos, S. M., & Scherr, R. E. (2020). Adolescent
Obesity: Diet Quality, Psychosocial Health, and Cardiometabolic Risk
Factors. Nutrients 2020, 1–22. https://doi.org/doi:10.3390/nu12010043

Utami, A. P., Probosari, E., & Panunggal, B. (2018). Faktor Risiko Status
Obesitas terhadap Kejadian Gangguan Psikososial pada remaja Putri di
Semarang. Media Penelitian Dan Pengembangan Kesehatan, 28(1), 57–66.
https://doi.org/10.22435/mpk.v28i1.7941.57-66

35
L
A
M
P
I
R
A
N
36
 Faktor Risiko Status Obesitas terhadap ... (Anggit Putri Utami, Enny Probosari, dan Binar Panunggal)

Faktor Risiko Status Obesitas terhadap Kejadian Gangguan

Psikososial pada Remaja Putri di Semarang
Risk Factors of Obesity Status on Psychosocial Disorders in Adolescent Girls in Semarang

Anggit Putri Utami*, Enny Probosari, dan Binar Panunggal

Program Studi Ilmu Gizi, Fakultas Kedokteran, Universitas Diponegoro, Jl. dr. Suetomo No. 18
Semarang, Komplek Zona Pendidikan RSUP dr. Kariadi Semarang, Jawa Tengah, Indonesia
*Korespondensi Penulis: anggitputri@yahoo.co.id

Submitted: 26-11-2017, Revised: 22-03-2018, Accepted: 23-11-2018

DOI: 10.22435/mpk.v28i1.7941.57-66

Abstrak
Angka prevalensi obesitas pada remaja usia 13-15 tahun di Semarang dua kali angka prevalensi
Provinsi Jawa Tengah. Dampak dari obesitas yang dapat terjadi pada remaja tidak hanya permasalahan
kesehatan, namun juga permasalahan psikososial. Penelitian ini bertujuan untuk mengetahui status
obesitas sebagai faktor risiko kejadian gangguan psikososial pada remaja putri di Semarang. Penelitian
ini menggunakan desain case control. Jumlah subjek sebanyak 92 remaja putri usia 13-15 tahun yang
dibagi menjadi 2 kelompok. Subjek terdiri dari 46 obesitas dan 46 gizi normal. Subjek diminta untuk
mengisi 5 kuesioner yaitu Pediatric Symptom Checklist-17 (PSC-17), Body Shape Questionnaire-16
(BSQ-16), Rosenberg Self-Esteem Scale (RSES), Bullying Behaviour Measurement, dan Children
Depression Inventory (CDI). Data dianalisis menggunakan uji chi-square. Terdapat perbedaan
gangguan psikososial antara remaja putri obesitas dan remaja putri gizi normal (p = 0,000). Remaja
putri obesitas memiliki risiko mengalami gangguan psikososial 6,395 kali dibandingkan remaja putri gizi
normal. Terdapat perbedaan citra tubuh (p = 0,000), harga diri (p = 0,022), dan perundungan (p = 0,003)
antara remaja putri obesitas dan remaja putri gizi normal. Tidak terdapat perbedaan depresi antara
remaja putri obesitas dan remaja putri gizi normal (p = 0,186). Obesitas sebagai faktor risiko kejadian
gangguan psikososial pada remaja putri. Gangguan psikososial yang terjadi pada remaja putri obesitas
adalah citra tubuh negatif, harga diri rendah, dan perundungan.
Kata kunci: obesitas, psikososial, remaja putri

Abstract
Obesity prevalence rate for adolescents aged 13-15 years in Semarang is twice the prevalence rate of
Central Java province. The impact of obesity that can occur in teenagers is not only health problems, but
also psychosocial problems. The aim of this study was to determine the status of obesity as a risk factor
for psychosocial disorders in adolescent girls in Semarang. This study used case control design. The
number of subject as many as 92 adolescent girls aged 13-15 years which were divided into 2 groups.
Subjects were consisted of 46 obese and 46 normal (healthy weight). Subjects were asked to complete
5 questionnaires: Pediatric Symptom Checklist-17 (PSC-17), Body Shape Questionnaire-16 (BSQ-16),
Rosenberg Self-Esteem Scale (RSES), Bullying Behaviour Measurement, and Children Depression
Inventory (CDI). Data were analyzed using chi-square test. There were differences in psychosocial
disorders between obese and normal adolescent girls (p = 0.000). Obese adolescent girls have a risk
of psychosocial disorders 6.935 times compared to normal adolescent girls. There were differences in
body image (p = 0.000), self-esteem (p = 0.022), and bullying (p = 0.003) between obese and normal
adolescents girls. There was no difference in depression between obese and normal adolescent girls (p
= 0.186). Obesity as risk factor of psychosocial disorders in adolescent girls. Psychosocial disorders that
occur in obese adolescent girls are negative body image, low self-esteem, and bullying.
Keywords: obesity, psychosocial, adolescent girls

57
 Media Litbangkes, Vol. 28 No. 1, Maret 2018, 57 – 66
PENDAHULUAN
Obesitas merupakan salah satu
masalah kesehatan remaja yang tinggal di
negara berkembang.1 Obesitas menggambarkan
akumulasi lemak pada adiposit yang dapat terjadi
apabila asupan kalori dari konsumsi makanan
melebihi kebutuhan metabolisme tubuh untuk
pertumbuhan, perkembangan, dan aktivitas
fisik. Obesitas pada awal kehidupan dapat
menimbulkan peningkatan risiko obesitas pada
masa dewasa serta menyebabkan peningkatan
morbiditas dan mortalitas selama masa dewasa.2
Data Riset Kesehatan Dasar (Riskesdas)
2013 menunjukkan bahwa prevalensi remaja
gemuk usia 13-15 tahun meningkat dari 2,5%
pada tahun 2010 menjadi 10,8% pada tahun 2013
yang terdiri dari 8,3% berat badan lebih dan 2,5%
obesitas. Menurut data Riskesdas Jawa Tengah
tahun 2013 menunjukkan prevalensi obesitas
provinsi pada remaja usia 13-15 tahun mencapai
2,4%. Sedangkan angka prevalensi obesitas
pada remaja usia 13-15 tahun di Kota Semarang
sebesar 4,9%, dimana dua kali lipat lebih tinggi
dari angka prevalensi provinsi Jawa Tengah.3-5
Permasalahan yang dapat terjadi pada
remaja obesitas selain permasalahan kesehatan
adalah psikososial. Penelitian di Bandung
menunjukkan bahwa masalah psikososial lebih
banyak terjadi pada remaja obesitas dibandingkan
remaja gizi normal.6 Gangguan atau permasalahan
psikososial dapat disebabkan karena pengaruh
dari stigma. Stigma obesitas dapat menyebabkan
remaja obesitas memiliki ketidakpuasan terhadap
citra tubuhnya dan mempunyai harga diri yang
lebih rendah daripada remaja dengan berat badan
normal. Remaja yang memiliki rasa ketidakpuasan
akan citra tubuhnya dan memiliki harga diri
yang rendah dapat memicu adanya kejadian
perundungan. Perundungan yang dilakukan
dapat dalam bentuk secara fisik seperti didorong,
dipukul, atau ditendang, dapat juga berupa ejekan
dan dikucilkan. Bentuk perundungan yang terjadi
pada remaja obesitas merupakan suatu prediktor
terjadinya depresi. Dimana remaja putri yang
obesitas memiliki risiko 3,6 kali lebih tinggi
untuk mengalami perundungan.7-10
Remaja putri cenderung lebih mengalami
gangguan dan permasalahan psikososial. Hal ini
terjadi karena remaja putri memiliki penilaian
negatif terhadap tubuhnya dan mereka lebih
memiliki ketertarikan yang tinggi terhadap
hubungan interpersonal.11 Remaja putri memiliki
korelasi yang lebih tinggi pada persepsi berat
58
badan bila dibandingkan dengan remaja putra.12
Ketidakpuasan akan citra tubuh yang terjadi
pada remaja putri dapat memicu terjadinya
perundungan dan depresi.11
Berdasarkan teori-teori tersebut, peneliti
ingin mengetahui status obesitas sebagai faktor
risiko kejadian gangguan psikososial pada remaja
putri di Semarang.
METODE
Penelitian ini dilaksanakan di SMP Islam
Al Azhar 23, SMP IT Insan Cendekia, SMP
Nurul Islam, SMP H. Isriati, dan SMP Islam
Hidayatullah Semarang. Penelitian ini merupakan
studi kuantitatif-kualitatif dengan desain case
control.
Populasi pada penelitian ini adalah
seluruh siswa putri dari kelima sekolah
tersebut. Pengambilan subjek diawali dengan
melakukan skrining terhadap seluruh siswa untuk
mengategorikan status gizi yang mengacu pada
Keputusan Kementerian Kesehatan Republik
Indonesia nomor 1995/MENKES/SK/XII/2010
yaitu berdasarkan nilai Z-score Indeks Massa
Tubuh menurut Usia (IMT/U). Siswa yang
memiliki nilai Z-Score IMT/U lebih dari 3 SD
dikategorikan obesitas, nilai Z-Score IMT/U
lebih dari 2 SD sampai 3 SD dikategorikan berat
badan lebih, dan nilai Z-Score IMT/U -2 sampai
dengan 2 SD dikategorikan gizi normal.13 Metode
pengambilan subjek dengan cara simple random
sampling untuk mendapatkan 46 subjek pada
masing-masing kelompok sehingga total subjek
dalam penelitian ini berjumlah 92 subjek. Subjek
obesitas dan berat badan lebih dimasukkan dalam
kelompok kasus, sementara subjek gizi normal
dimasukkan dalam kelompok kontrol.
Data yang dikumpulkan dalam penelitian
ini adalah identitas subjek, data berat badan dan
tinggi badan, data gangguan psikososial, citra
tubuh, harga diri, perundungan, dan depresi.
Penghitungan status gizi remaja menggunakan
software WHO AnthroPlus. Pengambilan data
gangguan psikososial menggunakan Pediatric
Symptom Checklist-17 (PSC-17). Pengambilan
data persepsi citra tubuh menggunakan Body
Shape Questionnaire-16 (BSQ-16). Pengambilan
data harga diri menggunakan Rosenberg Self-
Esteem Scale (RSES). Pengambilan data
perundungan menggunakan kuesioner Bullying
Behaviour Measurement. Pengambilan data
depresi menggunakan Children Depression
Inventory (CDI).
 Faktor Risiko Status Obesitas terhadap ... (Anggit Putri Utami, Enny Probosari, dan Binar Panunggal)
Pediatric Symptom Checklist-17 (PSC-17)
merupakan alat yang digunakan untuk mengukur
masalah psikososial yaitu berupa kuesioner
yang terdiri atas 17 pertanyaan. Tujuh belas
pertanyaan dibagi menjadi 5 pertanyaan subskala
internalisasi,7 pertanyaan subskala eksternalisasi,
dan 5 pertanyaan subskala perhatian, masing-
masing pertanyaan memiliki skor 0, 1, dan 2. Skor
masing-masing subskala dijumlahkan dan jumlah
skor tersebut dijadikan skor total. Kuesioner PSC-
17 dirancang untuk mengenali masalah kognitif,
emosi, dan perilaku sehingga intervensi yang
tepat dapat segera diinisiasi. Dicurigai terdapat
masalah psikososial jika jumlah skor internalisasi
≥ 5, jumlah skor perhatian ≥ 7, jumlah skor
eksternasilasi ≥ 7, atau skor total ≥ 15.6
Body Shape Questionnaire-16 (BSQ-
16) merupakan alat ukur yang digunakan untuk
menilai persepsi tubuh melalui serangkaian
pertanyaan yang mendalam. BSQ yang
digunakan adalah BSQ-16, digunakan skala
bertingkat dengan pilihan jawaban 1 sampai
6 pilihan jawaban untuk menunjukkan tingkat
ketidakpuasan akan bentuk tubuh. Kategori
pilihan jawaban 1 sampai 6 secara berturut-turut
yaitu tidak pernah, jarang, kadang-kadang, sering,
sering sekali, dan selalu. Skor akhir diperoleh
dari penjumlahan dari keseluruhan item. Citra
tubuh kemudian dikategorikan menjadi citra
tubuh negatif apabila skor total lebih dari kuarti
1 (> Q1) dan citra tubuh positif apabila skor total
kurang dari atau sama dengan kuartil 1 (≤ Q1).14
Rosenberg Self-Esteem Scale (RSES)
merupakan alat ukur yang digunakan untuk
mengukur tingkat harga diri. Skala ini memuat 10
item yang menggunakan format Likert dengan 4
kategori yang di skor 0 hingga 3. Kategori respons
yang diberikan adalah sangat setuju, setuju,
tidak setuju, dan sangat tidak setuju. Sepuluh
item pertanyaan tersebut memiliki item kriteria
positif (favourable) sebagai kriteria kepercayaan
diri (self confidence) dan item kriteria negatif
(unfavourable) sebagai aspek penurunan percaya
diri (self depreciation). Skor yang lebih tinggi
menunjukkan harga diri yang tinggi.15
Perilaku perundungan pada remaja
dapat diketahui dengan menggunakan kuesioner
Bullying Behaviour Measurement. Masing-
masing pertanyaan diberikan pilihan jawaban
yaitu tidak pernah, sekali atau dua kali, 2 atau
3 kali dalam sebulan, sekali dalam seminggu,
beberapa kali dalam seminggu. Remaja yang
menjawab mengalami perundungan lebih dari
sama dengan 2 sampai 3 minggu dalam sebulan
dikategorikan sebagai korban perundungan.
Remaja putri yang menjawab melakukan
perundungan lebih dari sama dengan 2 sampai
3 minggu dalam sebulan dikategorikan sebagai
pelaku perundungan. Remaja yang menjawab
mengalami dan melakukan perundungan lebih
dari sama dengan 2 sampai 3 minggu dalam
sebulan dikategorikan sebagai korban dan pelaku
perundungan.16 Kemudian, peneliti melakukan
wawacara kepada remaja yang menjadi pelaku
perundungan dan korban perundungan yang
bertujuan untuk mendukung data kuantitatif.
Children Depression Inventory
merupakan alat untuk mengukur skala depresi
untuk anak usia lebih dari 9 tahun yang
dikembangkan oleh Kovacs. Instrumen ini
memiliki 27 item pertanyaan untuk menilai
keparahan dari gejala depresi. Batasan nilai pada
pemeriksaan ini adalah 15, apabila nilai hasil
pemeriksaan mencapai 15 atau lebih, maka anak
tersebut dikategorikan menderita depresi. Bila
nilai yang didapat anak terletak pada rentang 0
hingga 14, maka anak tersebut dikategorikan
tidak depresi.17
Pengolahan dan analisis data dilakukan
dengan program komputer. Analisis univariat
untuk mendeskripsikan kategori, rerata, standar
deviasi, nilai minimal dan maksimal semua
variabel yang diambil. Uji bivariat dengan uji chi-
square untuk menganalisis status obesitas sebagai
faktor risiko terjadinya gangguan psikososial
pada remaja putri.
HASIL
Total subjek pada penelitian ini sebanyak
92 remaja putri yang terdiri dari 46 remaja
obesitas dan 46 remaja gizi normal dengan rerata
usia 13,82 tahun (Tabel 1). Setelah dilakukan
uji chi-square, didapatkan hasil bahwa terdapat
perbedaan gangguan psikososial antara remaja
putri obesitas dan remaja putri gizi normal (p =
0,000). Angka kejadian gangguan psikososial
lebih tinggi pada kelompok obesitas daripada
kelompok gizi normal. Pada kelompok obesitas
terdapat 28 dari 46 remaja putri yang mengalami
gangguan psikososial, sedangkan kelompok
gizi normal terdapat 9 dari 46 remaja putri yang
mengalami gangguan psikososial (Tabel 3).
Remaja putri dengan status gizi obesitas memiliki
risiko mengalami gangguan psikososial 6,395
kali dibandingkan remaja putri dengan status gizi
normal.
59
 Media Litbangkes, Vol. 28 No. 1, Maret 2018, 57 – 66

Tabel 1. Karakteristik Subjek Penelitian

n (%) x (SD)
Jenis Kelamin Perempuan 92 (100)
Usia 13 37 (40,2) 13,82 (0,79)
14 35 (38,0)
15 20 (21,8)
Status Gizi Obesitas 46 (50)
Gizi Normal 46 (50)

Tabel 2. Karakteristik Citra Diri, Harga Diri, dan Depresi

Citra Tubuh Harga Diri Depresi
Rerata 44,40 15,57 12,80
Standar Deviasi (SD) 19,985 3,821 6,420
Minimal 16 3 2
Maksimal 96 26 41
Kuartil 1 (Q1) 27,00 14,00 8,25
Kuartil 2 (Q2) 39,50 15,00 12,00
Kuartil 3 (Q3) 59,00 18,00 16,75

Tabel 3. Karakteristik Citra Diri, Harga Diri, dan Depresi

Status Gizi
Nilai p OR*
Obesitas Gizi Normal
n n
Gangguan Psikososial Ya 28 9 0,000 6,395
Tidak 18 37
Total 46 46

Citra Tubuh Negatif 43 25 0,000 12,04

Positif 3 21
Total 46 46

Harga Diri Rendah 30 18 0,022 2,917

Tinggi 16 28
Total 46 46

Perundungan Korban 21 6 0,003 NA**

Pelaku 2 6
Korban /Pelaku 6 5
Bukan Korban /Pelaku 17 29
Total 46 46

Depresi Ya 19 12 0,186 1,994

Tidak 27 34
Total 46 46
*95% CI
**NA karena tabel
≥ 2x2

60
 Faktor Risiko Status Obesitas terhadap ... (Anggit Putri Utami, Enny Probosari, dan Binar Panunggal)
Rerata skor citra tubuh remaja putri
pada penelitian ini adalah 44,40 ± 19,985
dengan nilai kuartil 1 adalah 27. Remaja putri
yang memiliki skor citra tubuh lebih dari 27
maka dikategorikan memiliki citra tubuh yang
positif, sedangkan remaja putri yang memiliki
skor citra tubuh kurang dari atau sama dengan
27 maka dikategorikan memiliki citra tubuh
yang negatif.14 Rerata skor harga diri remaja
putri pada penelitian ini adalah 15,57 ± 3,821.
Remaja putri yang memiliki skor harga diri
lebih dari 15,57 maka dikategorikan memiliki
harga diri tinggi, sedangkan remaja putri yang
memiliki skor harga diri kurang dari atau sama
dengan 15,57 maka dikategorikan memiliki
harga diri rendah. Rerata skor depresi remaja
putri pada penelitian ini adalah 12,80 ± 6,420
(Tabel 2).
Hasil uji chi-square menunjukkan bahwa
terdapat perbedaan citra tubuh antara remaja
putri obesitas dan remaja putri gizi normal (p =
0,000). Pada kelompok obesitas terdapat 43 dari
46 remaja putri memiliki citra tubuh negatif,
sedangkan kelompok gizi normal terdapat 25
dari 46 remaja putri yang memiliki citra tubuh
negatif. Remaja putri dengan status gizi obesitas
memiliki risiko untuk memiliki citra tubuh yang
negatif sebesar 12,04 kali dibandingkan remaja
putri dengan status gizi normal.
Pada variabel harga diri menunjukkan
bahwa terdapat perbedaan harga diri antara
remaja putri obesitas dan remaja putri gizi
normal (p = 0,022). Sebanyak 30 dari 46 remaja
putri kelompok obesitas memiliki harga diri yang
rendah, sedangkan pada kelompok gizi normal
sebanyak 18 dari 46 remaja yang memiliki harga
diri yang rendah. Remaja putri obesitas memiliki
risiko 2,917 kali untuk memiliki harga diri yang
rendah daripada remaja putri gizi normal.
Terdapat perbedaan peran dalam
kejadian perundungan pada remaja putri obesitas
dan remaja putri gizi normal (p = 0,003). Remaja
putri obesitas cenderung menjadi korban
perundungan di sekolah. Berbeda dengan
remaja putri gizi normal yang cenderung tidak
memiliki peran dalam kejadian perundungan.
Gejala depresi tidak memiliki perbedaan
antara remaja putri obesitas dan remaja putri gizi
normal, karena nilai p lebih dari 0,05 (p = 0,186).
Remaja putri obesitas memiliki risiko 1,994 kali
untuk memiliki gejala depresi daripada remaja
putri gizi normal.
PEMBAHASAN
Gangguan Psikososial
Gangguan psikososial adalah setiap
perubahan dalam kehidupan individu baik
yang bersifat psikologis ataupun sosial
yang mempunyai pengaruh timbal balik dan
dianggap berpotensi cukup besar sebagai
faktor penyebab terjadinya gangguan kesehatan
jiwa atau gangguan kesehatan secara nyata,
atau sebaliknya masalah kesehatan jiwa yang
berdampak pada lingkungan sosial. Gangguan
psikososial yang sering terjadi pada remaja
adalah adanya ketidakpuasan citra tubuh,
rendahnya harga diri, terjadinya perundungan,
dan depresi.7
Penelitian ini didapatkan hasil ada
perbedaan gangguan psikososial antara
remaja putri obesitas dan remaja putri gizi
normal. Remaja putri obesitas memiliki
risiko mengalami gangguan psikososial 6,395
kali dibandingkan remaja putri gizi normal.
Gangguan psikososial pada remaja putri obesitas
lebih tinggi dibandingkan remaja putri gizi
normal. Sebanyak 60,9% remaja putri obesitas
dan 19,6% remaja putri gizi normal mengalami
gangguan psikososial. Hasil ini sesuai dengan
penelitian di Bandung dimana dalam penelitian
tersebut juga menunjukkan masalah psikososial
yang tinggi pada remaja obesitas dibanding
dengan remaja gizi normal.6
Telah diketahui sebelumnya bahwa
anak obesitas mudah mengalami gangguan
psikososial karena memiliki rasa percaya diri
yang rendah, persepsi diri yang negatif, rasa
rendah diri, serta menjadi bahan ejekan teman-
temannya.6,15 Gangguan psikososial anak
obesitas dapat disebabkan oleh dua faktor, yaitu
faktor internal dan faktor eksternal. Faktor
internal merupakan faktor yang berasal dari anak
itu sendiri, yaitu keinginan untuk menguruskan
badan dan merasa berbeda dengan anak lain
sehingga anak obesitas mempunyai rasa percaya
diri yang rendah dan mudah mengalami depresi.
Faktor eksternal merupakan faktor yang berasal
dari lingkungan yang memberi stigma pada anak
61
 Media Litbangkes, Vol. 28 No. 1, Maret 2018, 57 – 66
obesitas yang dianggap sebagai anak yang malas,
bodoh, dan lamban. Lingkungan merupakan
keseluruhan fenomena fisik atau sosial yang
mempengaruhi atau dipengaruhi perkembangan
remaja, meliputi lingkungan keluarga, sekolah,
teman sebaya, dan masyarakat.6
Citra Tubuh
Citra tubuh merupakan persepsi
mengenai cara individu memandang, berpikir,
merasakan, dan bertindak terhadap bentuk dan
ukuran tubuhnya sendiri.18 Hal ini dipengaruhi
oleh bentuk dan ukuran tubuh aktualnya,
perasaannya tentang bentuk tubuhnya serta
harapan terhadap bentuk dan ukuran tubuh yang
diinginkan.19
Remaja putri obesitas pada penelitian ini
memiliki perbedaan citra tubuh dengan remaja
putri gizi normal. Sebanyak 93,5% remaja putri
obesitas dan 54,3% remaja putri gizi normal
memiliki citra tubuh negatif. Remaja putri
obesitas memiliki risiko untuk memiliki citra
tubuh negatif sebesar 12,04 kali dibanding
remaja putri gizi normal. Penelitian ini sesuai
dengan penelitian yang dilakukan di Portugal
dimana terdapat hubungan antara obesitas dan
ketidakpuasan citra tubuh. Remaja berat badan
lebih dan obesitas pada studi tersebut memiliki
rasa ketidakpuasan akan citra tubuhnya dan
berharap memiliki tubuh yang lebih kecil,
yaitu sebanyak 95,7% dan 77,6%.20 Selain itu,
penelitian ini sesuai dengan penelitian yang
dilakukan di Daerah Istimewa Yogyakarta
bahwa terdapat hubungan yang signifikan antara
obesitas dengan citra tubuh.14
Citra tubuh merupakan produk dari
persepsi yang terbentuk melalui proses individu
memandang tubuhnya dan tubuh orang lain,
kemudian individu melakukan perbandingan
antara kedua tubuh tersebut dan untuk
selanjutnya menginternalisasi perbandingan
tersebut.21 Internalisasi bentuk tubuh yang ideal
tersebut tampaknya sebagai faktor psikologi
yang menonjol dalam hubungan antara status
berat badan dan citra tubuh.18
Faktor-faktor lain yang berperan dalam
hubungan yang kompleks antara status berat
badan dan citra tubuh adalah pengaruh sosial,
seperti perbandingan sosial, fat talk, dan
62
perundungan yang berhubungan dengan berat
badan. Perbandingan sosial yang merupakan
kecenderungan untuk membandingkan
tubuh atau fisik seseorang dengan orang
lain (biasanya dalam suatu kelompok umur)
sangat relevan dikalangan remaja. Fat talk
didefinisikan sebagai komentar atau percakapan
negatif tentang tubuh dan berat badan yang
berhubungan dengan ketidakpuasan citra
tubuh di kalangan remaja. Fat talk juga dapat
berimbas menjadi perundungan yang berkaitan
dengan berat badan. Remaja berat badan lebih
dan obesitas lebih cenderung menjadi target
perundungan. Tingginya ketidakpuasan citra
tubuh pada remaja putri berhubungan dengan
tingginya prevalensi kejadian perundungan
di sekolah. Selain itu, harga diri yang rendah
dan ketidakpuasan tubuh bertindak sebagai
perantara hubungan antara status berat badan
dan perundungan. Oleh karena itu, remaja berat
badan lebih dan obesitas mungkin sangat rentan
mengalami perundungan jika mereka memiliki
harga diri yang lebih rendah dan ketidakpuasan
citra tubuh yang lebih tinggi.18
Harga Diri
Harga diri adalah hasil penilaian
individu terhadap dirinya yang diungkapkan
dalam sikap yang positif atau negatif. Individu
dengan harga diri yang tinggi akan menghargai
diri sendiri dan menyadari keterbatasannya.
Sedangkan individu dengan harga diri rendah
biasanya mengalami penolakan, ketidakpuasan,
dan meremehkan dirinya sendiri.22
Penelitian ini menunjukkan bahwa
terdapat perbedaan tingkat harga diri antara
remaja putri obesitas dan remaja putri gizi
normal. Sebanyak 65,2% remaja putri obesitas
dan 39,1% remaja gizi normal yang memiliki
harga diri yang rendah. Hasil penelitian ini
sesuai dengan penelitian yang dilakukan di
Taiwan yang menunjukkan bahwa remaja berat
badan lebih dan obesitas memiliki tingkat harga
diri yang rendah daripada remaja dengan berat
badan rata-rata.15
Berat badan berhubungan dengan harga
diri yang rendah. Remaja putri obesitas memiliki
risiko 2,917 kali untuk memiliki harga diri
yang rendah dibandingkan dengan remaja putri
 Faktor Risiko Status Obesitas terhadap ... (Anggit Putri Utami, Enny Probosari, dan Binar Panunggal)
gizi normal. Hasil penelitian ini sesuai dengan
penelitian di Jerman bahwa remaja obesitas dan
berat badan lebih memiliki risiko 2 kali dan
1,3 kali lebih tinggi untuk memiliki harga diri
yang rendah jika dibandingkan dengan remaja
dengan berat badan gizi normal.23 Remaja awal
putri dengan status gizi berat badan lebih dan
obesitas memiliki harga diri yang lebih rendah
karena adanya perbedaan antara penampilan
fisik yang mereka rasakan dan standar bentuk
tubuh.24 Remaja berat badan lebih dan obesitas
cenderung lebih dipengaruhi oleh komentar-
komentar negatif dari teman sebaya tentang
penampilan mereka sehingga menyebabkan
remaja memiliki harga diri yang rendah yang
dapat menyebabkan remaja tersebut menjadi
korban perundungan.24
Perundungan
Perundungan sebagai salah satu tindakan
agresif yang rentan terjadi pada remaja. Perilaku
perundungan dapat terjadi pada berbagai
tempat, mulai dari lingkungan pendidikan atau
sekolah, tempat kerja, lingkungan tetangga,
tempat bermain, dan lain-lain. Remaja obesitas
sering mengalami perundungan karena adanya
stigma yang ditimbulkan oleh lingkungan.25
Stigma merupakan tanda atau sifat yang
menghubungkan seseorang dengan karakteristik
yang tidak diinginkan atau stereotip yang
negatif.7
Penelitian ini menunjukkan bahwa
remaja putri obesitas lebih sering terlibat
sebagai korban perundungan. Hal ini sama
dengan penelitian di China bahwa jika dilihat
dari signifikansinya, korban perundungan
secara signifikan berhubungan dengan remaja
putri.26 Perundungan dapat disebabkan karena
adanya stigma obesitas. Orang obesitas sering
dianggap malas dan tidak rapi sehingga individu
obesitas sering mengalami penolakan sosial.
Mereka sering mengalami perundungan secara
fisik oleh teman sebayanya misalnya didorong,
dipukul, ditendang, diejek, dan dikucilkan.7
Pada penelitian ini, jenis perundungan yang
sering terjadi adalah perundungan verbal.
Serupa dengan penelitian yang dilakukan di
Brazil bahwa jenis perundungan yang sering
terjadi pada remaja adalah perundungan verbal,
terutama panggilan nama dan menyebarkan
rumor.27
Selain mendapatkan data dari kuesioner,
peneliti melakukan wawancara kepada pelaku
dan korban perundungan. Wawancara kepada
pelaku perundungan bertujuan untuk mengetahui
alasan melakukan perundungan terkait berat
badan dan obesitas. Sedangkan wawancara
kepada korban perundungan bertujuan untuk
mengetahui bentuk kejadian perundungan
terkait berat badan dan obesitas.
Subjek pelaku 1 menyatakan bahwa,“…
buat lelucon aja mbak. Buat lucu-lucuan aja,
biar di kelas lebih rame. Terus kadang juga
karena ikut-ikutan temen. Misal ada yang diejek
ya nanti saya ikut-ikutan ngejekin gitu.”
Subjek pelaku 2 menyatakan bahwa,
“…aku ngrasanya badanku tu lebih bagus dari
dia, ngga gemuk, jadinya ya seneng aja buat
ngejekin. Ya buat lucu-lucuan aja sih mbak
sebenernya.”
Subjek pelaku 3 menyatakan bahwa,
“…ya cuma karena ikut-ikutan aja ya, seneng
aja ngejek-ngejek gitu, kan seru juga. Tapi
sebenarnya dalam hati kecil saya itu. saya
sebenernya saya nggak tega, karena bullying
itu termasuk penghinaan. Penghinaan itu kalo
kita yang dibully itu bakalan ngerasa terhina
banget. Jadi kalo saya ngebully itu rasanya
nggak sengaja, cuma ikut-ikutan temen aja.”
Subjek pelaku 4 menyatakan bahwa,
“…alasannya karena kan kalo kita lihat orang
gendut itu kesannya orangnya itu males-
malesan, cewek gendut itu lemah. Jadinya tuh
sering diejekin.”
Sesuai dengan hasil wawancara, dapat
diketahui bahwa alasan pelaku perundungan
melakukan perundungan adalah bercanda, ikut-
ikutan teman, dan stigma obesitas.
Subjek korban 1 menyatakan bahwa,
“…pernah mbak. Palingan pas mereka lagi
gerombol aja kedengeran lagi ngomongin aku.
…ya kayaknya ngomongin kalo aku gemuk.”
Subjek korban 2 menyatakan bahwa,
“…iya pernah, tapi ya cuma kayak bercanda aja
gitu sih…Ga ada panggilan atau julukan apa-
apa mbak…Kalo temen aku becandanya cuma
yang kayak ‘ih kamu menuh-menuhin tempat o’.
Kayak gitu aja biasanya.”
63
 Media Litbangkes, Vol. 28 No. 1, Maret 2018, 57 – 66
Subjek korban 3 menyatakan bahwa,
“…pernah mbak. Sama anak-anak cowok
yang nakal itu ya kalo pas saya lewat, mereka
bilangnya, kamu tu gimana sih gendut, menuh-
menuhin jalan aja. Pas olahraga juga diejek
nggak bisa lari. Kalo sama temen-temenku yang
cewek paling ya sering dibilang gendut, gendut
gitu mbak.”
Subjek korban 4 menyatakan bahwa,
“…pernah. Dipanggil gendut mbak. Kalo aku
habis dari kantin bawa jajan gitu ya ada yang
bilang ‘gendut makan terus nggak bagi-bagi’
gitu mbak.”
Sesuai dengan hasil wawancara, dapat
diketahui bahwa jenis perundungan yang sering
terjadi adalah perundungan verbal, terutama
panggilan nama atau julukan.
Depresi
Remaja dengan berat badan lebih dan
obesitas yang mengalami perundungan tentang
berat badan memiliki peningkatan risiko untuk
mengalami kesehatan psikologi yang buruk
seperti kurang percaya diri, harga diri yang
rendah, ketidakpuasan akan bentuk tubuh dan
depresi.9 Namun pada penelitian ini tidak ada
perbedaan depresi antara remaja putri obesitas
dan remaja putri gizi normal. Hasil penelitian ini
sesuai dengan hasil penelitian yang dilakukan di
Padang bahwa didapatkan korelasi yang lemah
antara Indeks Massa Tubuh (IMT) dan Skor
CDI.17 Begitupun penelitian yang dilakukan
di Surabaya yang menunjukkan bahwa tidak
terdapat hubungan antara tingkat obesitas dan
gejala depresi pada remaja di Surabaya.28 Hasil
penelitian di Seattle juga melaporkan bahwa
IMT tidak berkaitan dengan depresi. Hal ini
mungkin terjadi karena teori psikososial yang
menyatakan bahwa akibat berat badan lebih dan
obesitas (seperti rendahnya harga diri, stigma,
dan isolasi sosial) yang menyebabkan gejala
depresi lebih lambat berkembang terutama pada
anak-anak yang masih pada tahap awal masa
remaja.29
KESIMPULAN
Penelitian ini didapatkan hasil ada
perbedaan gangguan psikososial antara remaja
putri obesitas dan remaja putri gizi normal (p =
64
0,000), dimana remaja putri obesitas memiliki
risiko mengalami gangguan psikososial 6,395
kali dibandingkan dengan remaja putri gizi
normal. Terdapat perbedaan citra tubuh (p =
0,000), harga diri (p = 0,022), dan perundungan
(p = 0,003) antara remaja putri obesitas dan
remaja putri gizi normal. Tidak terdapat
perbedaan depresi antara remaja putri obesitas
dan remaja putri gizi normal (p=0,186).
SARAN
Kelompok remaja obesitas dan remaja
gizi normal sebaiknya mengikuti program
manajemen berat badan, karena program
manajemen berat badan dapat memperbaiki
citra tubuh atau penampilan fisik kemudian
menyebabkan perubahan harga diri. Apabila
telah terjadi perubahan harga diri menjadi
lebih baik maka diharapkan dapat mengurangi
perilaku perundungan di sekolah. Program
manajemen berat badan dapat dilakukan dengan
memperbaiki pola makan dan meningkatkan
aktivitas fisik seperti olahraga sebagai tindakan
kuratif untuk remaja obesitas dan tindakan
preventif untuk remaja gizi normal.
UCAPAN TERIMA KASIH
Terima kasih peneliti sampaikan kepada
pembimbing dan penguji atas bimbingan,
saran, dan masukan yang membangun untuk
karya tulis ini. Terima kasih kepada orang tua
dan keluarga yang mendoakan, seluruh subjek
yang berpartisipasi dalam penelitian ini, kepala
sekolah dan guru setiap sekolah, sahabat,
enumerator yang telah membantu dan semua
pihak yang telah memotivasi dan mendukung
sehingga penelitian ini dapat diselesaikan.
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Path Analysis on the Psychosocial Impact of Obesity or

Overweight in Adolescents in Surakarta, Central Java
Yayang Kharistik A1), Yulia Lanti R. D2), C.S.P. Wekadigunawan1)

1)Masters Program in Public Health, Universitas Sebelas Maret

2)Faculty of Medicine, Universitas Sebelas Maret

ABSTRACT

Background: Worldwide obesity shares 33 percent of adolescents body mass index. The
prevalence of obesity has increased threefold since 1980. In Indonesia there are 10.8 percent of
children aged 13-15 years who are obese. Obesity and overweight can cause various chronic
diseases. Another important impact is psychosocial. Correct intervention and early prevention can
reduce the psychosocial impact. This study aimed to determine the psychosocial impact of obesity
or overweight on adolescents.
Subjects and method: This was an analytic observational study with cross-sectional design. The
study was conducted at 6 junior high schools in Banjarsari and Jebres, Surakarta, Central Java,
from October to November, 2017. A total sample of 160 junior high school students were selected
for this study by purposive sampling. The dependent variables were depression, self-assessment,
body image, eating disorder, and quality of life. The independent variables were obesity or
overweight. Body mass index (BMI) was measured by body weight scale and microtoise. Data of
other study variables were collected by questionnaire. The data were analyzed by path analysis.
Results: Obesity or overweight was directly associated with depression (b= 1.04; 95% CI= 0.32 to
1.77; p= 0.005) and bad body image (b= -2.35; 95% CI= -3.20 to 1.49; p< 0.001). Depression was
directly associated with eating disorder (b= 0.55; CI 95%= -0.87 to 1.18; p=0.091) and poorer
quality of life (b= -0.64; 95% CI= -1.34 to 0.69; p= 0.077). Good body image was directly
asssociated with positive self-assessment (b= 2.71; 95% CI= 1.89 to 3.52; p<0.001).
Conclusion: Obesity or overweight in adolescents is directly asssociated with depression and bad
body image. Obesity or overweight is indirectly associated with negative self-assessment, eating
disorder, and poorer quality of life.

Keyword: overweight, obesity, psychosocial, path analysis

Correspondence:
Yayang Kharistik Almasith. Masters Program in Public Health, Universitas Sebelas Maret, Jl. Ir.
Sutami 36 A, Surakarta 57126, Central Java. Email: ycharistik@yahoo.com.
Mobile: +6281229474445

LATAR BELAKANG dunia yang mengalami obesitas dan berat

Obesitas dan berat berlebih merupakan
masalah kesehatan di seluruh dunia. World
Health Organization (WHO) menyatakan
bahwa obesitas dan berat berlebih sudah
merupakan epidemi global. Obesitas dan
berat berlebih merupakan ancaman bagi
kesehatan populasi yang berkembang pesat
di sejumlah negara. Pada 2008 dinyatakan
200 juta penduduk laki-laki dan 300 juta
penduduk wanita mengalami obesitas di
dunia. Enam puluh lima persen populasi
berlebih mengalami kematian melebihi
masalah gizi buruk (WHO, 2016).
Masa remaja merupakan periode ter-
jadinya pertumbuhan dan perkembangan
yang pesat baik secara fisik, psikologis
maupun intelektual. Menurut WHO (2016)
remaja adalah penduduk dalam rentang
usia 10-19 tahun. Jumlah kelompok usia
10-19 tahun di Indonesia menurut sensus
penduduk 2010 sebanyak 43.5 juta atau
sekitar 18% dari jumlah penduduk. Pada

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Journal of Epidemiology and Public Health (2018), 3(2): 105-117
https://doi.org/10.26911/jepublichealth.2018.03.02.01
2013, terdapat 12 milyar remaja atau se-
kitar 17 persen dari populasi dunia, popu-
lasi remaja terbesar sepanjang sejarah
(Cherry et al., 2017). Amerika Serikat me-
nyatakan permasalahan obesitas dan berat
berlebih telah menjadi permasalahan kese-
hatan masyarakat yang signifikan. Terdapat
33 persen remaja mengalami obesitas
dimana remaja yang mengalami berat
berlebih mengalami peningkatan jumlah
sebanyak tiga kali lipat sejak 1980 dan
prevalensi obesitas pada remaja mengalami
peningkatan sebesar dua kali lipat (Baghci
dan Harry, 2013)
Indonesia saat ini menghadapi beban
ganda permasalahan nutrisi. Di satu sisi
belum berhasil menyelesaikan persoalan
gizi buruk atau gizi kurang tetapi disisi lain
Indonesia menghadapi masalah obesitas
atau kelebihan berat badan. Prevalensi
berat berlebih dan obesitas terus mening-
kat dan saat ini diperkirakan lebih dari 100
juta penduduk dunia menderita obesitas.
Prevalensi obesitas dan berat berlebih di
Indonesia juga telah mencapai tingkat
membahayakan. Menurut data Riset Kese-
hatan Dasar (Riskesdas) 2013, secara
nasional masalah gemuk pada anak usia 13-
15 tahun sebesar 10.8 persen yang terdiri
atas 8,3 persen gemuk dan 2,5 persen
sangat gemuk atau obesitas. Prevalensi
remaja obesitas dan berat berlebih di
Provinsi Jawa Tengah sebesar 9.5 persen,
sedangkan Kota Surakarta memiliki pre-
valensi yang lebih tinggi dari prevalensi
provinsi dan nasional yaitu 10.9 persen.
Menurut data Profil Dinas Kesehatan
Kota Surakarta (2015) sebanyak 6,829
remaja yang dilakukan pemeriksaan obe-
sitas, terdapat 2,861 remaja (41.89%)
remaja mengalami obesitas. Prevalensi ter-
banyak terdapat di Kecamatan Banjarsari
yaitu sebesar 68.57 persen remaja meng-
alami obesitas dan berat berlebih. Pering-
kat kedua yaitu 27.85 persen remaja obe-
106
sitas dan berat berlebih terdapat di Keca-
matan Jebres.
Obesitas pada remaja berisiko tinggi
menjadi obesitas pada masa dewasa dan
berpotensi menjadi penyebab berbagai
penyakit kardiovaskular serta metabolik.
Menurut data WHO, lebih dari 1.4 miliar
orang dewasa memiliki berat badan ber-
lebih dan 2.8 juta orang dewasa meninggal
tiap tahun karena obesitas dan berat ber-
lebih yang menyebabkan munculnya ber-
bagai penyakit kronis seperti diabetes dan
penyakit jantung. Obesitas juga telah
dikaitkan dengan spektrum luas lainnya,
selain diabetes tipe 2, penyakit degeneratif,
termasuk kelainan metabolik dan bentuk
kanker tertentu. Dilaporkan sebesar 80
persen menyebabkan diabetes tipe 2, 70%
penyakit kardiovaskular, dan 42 persen
menyebabkan kanker payudara dan kolon.
Obesitas adalah faktor utama di balik 30
gangguan kandung empedu, yang menye-
babkan pembedahan dan 26 insiden tekan-
an darah tinggi (Cherry et al., 2017).
Dampak lain yang juga penting yaitu
dampak terhadap tumbuh kembang ter-
utama aspek psikososial. Remaja gemuk
seringkali menderita bias sosial, prasangka
dan diskriminasi, tidak hanya oleh kalang-
an umum tetapi juga profesional kesehatan,
dan ini mungkin membuat mereka enggan
untuk mencari bantuan medis. Menurut
Roberts dan Duong (2013) dalam peneli-
tiannya menyebutkan bahwa obesitas be-
risiko lebih besar untuk kesehatan mental
yang buruk. Menyesuaikan usia dan pen-
dapatan keluarga serta gender, asosiasi bagi
kesehatan mental yang buruk semakin
kuat. Penelitian lain dilakukan oleh Endah
Pujiasti et al., (2013) yang menyebutkan
bahwa angka kejadian masalah psikososial
lebih tinggi pada kelompok remaja obesitas
daripada remaja dengan status gizi normal.
Pada kelompok remaja obesitas terdapat
15/31 orang mengalami masalah psiko-
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 Almasith et al./ Path Analysis on the Psychosocial Impact of Obesity
sosial. Kelompok remaja obesitas mem-
punyai relevansi masalah psikososial lebih
tinggi yang bermakna (p= 0.007) diban-
dingkan dengan kelompok gizi normal.
SUBJEK DAN METODE
1. Jenis dan Desain Penelitian
Rancangan penelitian ini merupakan pene-
litian analitik observasional dengan meng-
gunakan pendekatan cross sectional
(potong lintang). Dengan pendekatan
potong lintang, semua variabel yang diteliti
baik variabel independen maupun depen-
den diukur pada saat yang sama. Penelitian
dilaksanakan di enam Sekolah Menengah
Pertama di wilayah Kecamatan Jebres dan
Kecamatan Banjarsari Kota Surakarta.
Pengambilan data dilaksanakan pada bulan
Oktober - November 2017.
2. Populasi dan Sampel Penelitian
Populasi sasaran penelitian adalah Semua
remaja tengah (14-16 tahun) di Sekolah
Menengah Pertama Kota Surakarta. Popu-
lasi sumber (populasi terjangkau) peneli-
tian adalah Remaja tengah (14-16 tahun)
yang mengalami obesitas dan berat ber-
lebih di Sekolah Menengah Pertama wila-
yah Kecamatan Banjarsari dan Kecamatan
Jebres Kota Surakarta dan remaja normal,
sebesar 160 subjek dengan perbandingan
2:1:1 remaja berat normal: berat berlebih:
obesitas.
Teknik pengambilan subjek dalam
penelitian ini menggunakan simple
random sampling untuk pemilihan sekolah
dan purposive sampling untuk menentu-
kan subjek siswa. Pengambilan subjek
dilakukan atas dasar pertimbangan yang
menganggap unsur-unsur yang dikehen-
daki telah ada dalam anggota subjek yang
diambil. Terdapat tujuh variabel dalam
penelitian ini. Variabel dependen yaitu
depresi, penilaian diri, citra tubuh, gang-
guan makan dan kualitas hidup. Variabel
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independen yaitu obesitas dan berat ber-
lebih remaja.
3. Definisi Operasional Variabel
Definisi operasional variable obesitas
ditunjukkan indeks massa tubuh dengan
skala persentil lebih dari sama dengan 95
persentil menurut klasifikasi CDC tahun
2015. Berat berlebih ditunjukkan indeks
massa tubuh dengan skala persentil 85 ±
kurang dari 95 persentil menurut klasifikasi
CDC tahun 2015. Depresi yaitu respon
emosional dengan ciri mengalami satu atau
lebih gejala pada suasana hati, seperti
perasaan tertekan, bersalah, tak berdaya,
menarik diri, gelisah, sensitif hingga
keinginan menyakiti diri sendiri atau
oranglain. Penilaian diri yaitu penilaian ter-
hadap diri sendiri tentang seberapa ber-
harganya diri sendiri terhadap orang lain.
Citra tubuh yaitu keyakinan tentang
penampilan oleh diri sendiri serta gam-
baran perasaan diri terhadap tubuh sendiri.
Gangguan makan yaitu gangguan dalam
tingkah laku makan, seperti mengurangi
atau menambah kadar dan porsi makanan.
Kualitas hidup yaitu kondisi dimana sese-
orang dapat tetap merasa nyaman secara
fisik, psikologis, sosial maupun spiritual
serta secara optimal memanfaatkan hidup-
nya untuk kebahagiaan dirinya maupun
orang lain.
4. Pengumpulan Data
Pengumpulan data menggunakan kuesio-
ner. Instrumen yang diuji reliabilitas
adalah kuesioner penilaian diri, citra tubuh,
gangguan makan. Berdasarkan hasil uji
reliabilitas korelasi item-total variabel peni-
laian diri sebesar r hitung •0.22 dan
Cronbach Alpha •0.67. Seluruh butir per-
tanyaan dinyatakan reliabel.
5. Analisis Data
Penelitian ini menggunakan analisis jalur.
Analisis ini dapat menghitung besarnya
pengaruh langsung dan tidak langsung dari
setiap variabel bebas terhadap variabel
107
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https://doi.org/10.26911/jepublichealth.2018.03.02.01

terikat. Langkah-langkah melakukan anali- 2. Analisis Jalur

sis jalur yaitu spesifikasi model, identifikasi Gambar 1 menunjukkan model struktural
model, kesesuaian model, estimasi para- setelah dilakukan estimasi pengolahan data
meter, respesifikasi model. menggunakan aplikasi Stata 13 dengan
6. Etika Penelitian program SEM (Structural Equation
Etika penelitian dengan persetujuan pene- Modeling). Gambar 1 menjelaskan penga-
litian (informed consent), tanpa nama ruh langsung dan tidak langsung dampak
(anonimity), kerahasiaan (confidentiality) psikososial dari obesitas dan berat berlebih.
dan ethical clearance dari RSUD Dr. Nilai degree of freedom (df)= 27
Moewardi, Surakarta. menunjukkan over-identified sehingga
path analysis bisa dilakukan. Penelitian ini
HASIL telah sesuai dengan data sampel yang
1. Karakteristik Subjek Penelitian ditunjukan model saturasi dan juga
Karakteristik subjek dalam penelitian ini koefisien regresi yang bernilai lebih dari nol
dapat dilihat pada Tabel 1. serta secara statistik signifikan, sehingga
Tabel 1 menunjukkan karakteristik tidak perlu membuat ulang model analisis
subjek penelitian sebagian besar berjenis jalur.
kelamin laki-laki (57.5%). Pendidikan ayah Tabel 2 menunjukkan bahwa ada
97 (60.6%) berpendidikan rendah. Hal hubungan obesitas dan berat berlebih
yang sama pada pendidikan ibu yaitu remaja pada kejadian depresi dan secara
sebanyak 97 (60.6%) ibu berpendidikan statistik signifikan. Remaja yang meng-
rendah. Sebagian besar pekerjaan ayah alami obesitas atau berat berlebih lebih
adalah swasta (86.9%). Ibu yang bekerja di besar kemungkinan untuk mengalami
rumah sebanyak 87 (54.4%). Serta sebagian depresi (b= 1.04; CI 95%= 0.32 sd 1.77; p=
besar subjek penelitian memiliki jumlah 0.005).
saudara <2 (58.8%). Ada dampak dari obesitas dan berat
Tabel 1. Distribusi Frekuensi Karak- berlebih remaja pada citra tubuh remaja
teristik Subjek Penelitian dan dinyatakan sangat signifikan secara
Karakteristik n % statistik. Remaja yang mengalami obesitas
Jenis kelamin dan berat berlebih lebih besar kemung-
Laki-laki 92 57.5
kinan untuk mengalami citra tubuh yang
Perempuan 68 42.5
Pendidikan Ayah rendah (b= -2.35; CI 95%= -3.20 hingga
Rendah (< SMA) 97 60.6 1.49; p< 0.001).
7LQJJL • 60$ 63 39.4 Ada dampak dari gangguan makan
Pendidikan Ibu
Rendah (< SMA) 97 60.6
pada kualitas hidup remaja dan dinyatakan
7LQJJL • 60$ 63 39.4 sangat signifikan secara statistik. Remaja
Pekerjaan Ayah yang mengalami gangguan makan lebih
Swasta 139 86.9 besar kemungkinan mempunyai kualitas
Negeri 21 13.1
Pekerjaan Ibu hidup yang rendah. (b= -1.72; CI 95%= -
Bekerja di luar 73 45.6 2.46 hingga 0.98; p< 0.001).
Bekerja di rumah 87 54.4 Ada dampak dari tingkat pendidikan
Jumlah Saudara ibu pada kejadian obesitas dan berat
<2 94 58.8
•2 66 41.3 berlebih remaja dan signifikan secara
statistik. Remaja dengan tingkat pendidik-
an ibu yang rendah (<SMA) lebih besar

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 Almasith et al./ Path Analysis on the Psychosocial Impact of Obesity

kemungkinan mengalami obesitas dan remaja dan secara statistik signifikan.

berat berlebih (b= -0.68; CI 95%= -1.36 Remaja dengan ibu bekerja di luar rumah
hingga -0.14; p= 0.046). memiliki lebih besar kemungkinan meng-
Ada dampak dari status pekerjaan ibu alami obesitas dan berat berlebih. (b= 0.77;
pada kejadian obesitas dan berat berlebih CI 95%= 0.11 hingga 1.44; p= 0.022).

Gambar 1. Model struktural analisis jalur

Tabel 2. Hasil analisis jalur dampak psikososial dari obesitas dan berat berlebih
pada remaja
CI 95%
Koefisien
Variabel dependen Variabel independen Batas Batas p
Jalur
bawah atas
Direct Effect
Depresi Å Obesitas, berat berlebih 1.04 0.32 1.77 0.005
Citra tubuh Å Obesitas, berat berlebih -2.35 -3.20 -1.49 <0.001
Gangguan makan Å Kualitas hidup -1.72 -2.46 -0.98 <0.001
Obesitas, berat berlebih Å Pendidikan ibu -0.68 -1.36 -0.14 0.046
Å Pekerjaan ibu 0.77 0.11 1.44 0.022
Å Jumlah saudara 0.71 -1.37 0.76 0.034
Indirect Effect Å
Depresi Penilaian diri -0.91 -1.68 -0.15 0.020
Penilaian diri Citra tubuh 2.71 1.89 3.52 <0.001
Kualitas hidup Depresi -0.64 -1.34 0.69 0.077
Gangguan makan Depresi 0.55 -0.87 1.18 0.091
Pekerjaan ibu Pendidikan ibu 0.56 -0.08 1.19 0.089
Log likehood = -666.70685

Ada dampak dari jumlah saudara
pada kejadian obesitas dan berat berlebih
remaja dan signifikan secara statistik.
Remaja dengan jumlah saudara sedikit (<2)
memiliki lebih besar kemungkinan meng-
alami obesitas dan berat berlebih. (b= 0.71;
CI 95%= -1.37 hingga 0.76; p= 0.034).
Ada dampak dari citra tubuh pada
kejadian depresi melalui penilaian diri dan
secara statistik dinyatakan signifikan.
Remaja dengan penilaian diri yang rendah
memiliki lebih besar kemungkinan untuk
mengalami depresi. (b= -0.91; CI 95%= -
1.68 hingga -0.15; p= 0.020).

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Journal of Epidemiology and Public Health (2018), 3(2): 105-117
https://doi.org/10.26911/jepublichealth.2018.03.02.01
Ada dampak dari obesitas dan berat
berlebih remaja pada penilaian diri melalui
citra tubuh dan dinyatakan sangat signi-
fikan secara statistik. Remaja dengan citra
tubuh rendah lebih besar kemungkinan
mempunyai penilaian diri yang rendah (b=
2.71; CI 95%= 1.89 hingga 3.52; p< 0.001).
Ada dampak dari obesitas dan berat
berlebih remaja pada kualitas hidup me-
lalui kejadian depresi dan dinyatakan men-
dekati signifikan secara statistik. Remaja
yang mengalami depresi lebih besar mem-
punyai kualitas hidup yang rendah (b= -
0.64; CI 95%= -1.34 hingga 0.69; p=
0.077).
Ada dampak dari obesitas dan berat
berlebih pada gangguan makan melalui
depresi dan dinyatakan mendekati signifi-
kan secara statistik. Remaja yang meng-
alami depresi mempunyai kemungkinan
lebih besar mengalami gangguan makan
(b= 0.55; CI 95%= -0.87 hingga 1.18; p=
0.091).
Ada dampak dari tingkat pendidikan
ibu pada kejadian obesitas dan berat
berlebih remaja melalui status pekerjaan
ibu dan secara statistik dinyatakan men-
dekati signifikan. Remaja dengan tingkat
pendidikan ibu yang rendah kemungkinan
lebih besar memiliki ibu yang bekerja di
rumah (b= 0.56; CI 95%= -0.08 hingga
1.19; p= 0.089).
PEMBAHASAN
1. Dampak obesitas dan berat ber-
lebih remaja pada kejadian
depresi.
Hasil analisis didapatkan bahwa obesitas
dan berat berlebih remaja mempunyai
dampak secara langsung pada kejadian
depresi secara positif.
Obesitas didefinisikan memiliki kele-
bihan berat tubuh akibat penimbunan
lemak pada tubuh. Sedangkan kegemukan
atau berat berlebih didefinisikan kondisi
110
berat tubuh melebihi berat tubuh normal
(Centers for Disease Control and Prevent-
ion, 2017).
Arah paparan obesitas mengakibat-
kan depresi dapat dilihat secara biologis.
Obesitas atau berat berlebih merupakan
suatu keadaan peradangan, karena penam-
bahan berat badan telah terbukti meng-
aktifkan jalur inflamasi dalam tubuh.
Sedangkan peradangan itu sendiri, ber-
peran dalam terjadinya depresi. Sumbu
hipotalamus-hipofisis-adrenal (sumbu
HPA) dianggap berperan. Obesitas melibat-
kan disregulasi sumbu HPA dan diketahui
disregulasi sumbu HPA terlibat dalam
terjadinya depresi (Pasquali dan Vicennati,
2000). Selain itu, obesitas melibatkan
peningkatan risiko diabetes mellitus dan
peningkatan resistensi insulin yang dapat
menyebabkan perubahan pada otak dan
meningkatkan risiko depresi (Shoelson et
al., 2007).
Selain mekanisme biologis, kejadian
depresi yang disebabkan karena obesitas
dan berat berlebih pun dapat dijelaskan
secara mekanisme psikologis. Depresi
adalah respon emosional dengan ciri kepu-
tus asaan, motivasi berkurang, pengharga-
an terhadap diri rendah, proses berpikir
yang lambat, retardasi psikomotor serta
gangguan-gangguan makan dan tidur.
Kelebihan berat badan hingga obesitas dan
persepsinya dapat meningkatkan tekanan
psikologis (Atlantis dan Ball, 2008).
Sebagian masyarakat umum masih ber-
anggapan dan percaya bahwa kurus meru-
pakan wujud keindahan dan kecantikan
sebagai penerimaan sosial dan faktor
sosiokultural. Hal tersebut meningkatkan
ketidakpuasan tubuh dan mengurangi
harga diri, yang dimana hal tersebut me-
rupakan faktor risiko terjadinya depresi.
Pola makan dan tidur yang terganggu serta
mengalami sakit fisik merupakan konse-
kuensi langsung obesitas, dan juga diketa-
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 Almasith et al./ Path Analysis on the Psychosocial Impact of Obesity
hui dapat meningkatkan risiko depresi
(Derenne dan Beresin, 2014).
Hasil yang sama ditunjukkan oleh
penelitian Floriana. Luppino et al., (2010)
yang berjudul Overweight, Obesity, and
Depression: A Systematic Review and
Meta-analysis of Longitudinal Studies.
Studi literatur mencakup 15 penelitian yang
berasal dari PubMed, PsycINFO dan
EMBASE database yang diseleksi sesuai
kriteria. Hasil meta analisis menunjukkan
bahwa orang yang mengalami obesitas
berisiko 1.5 kali lebih tinggi untuk meng-
alami depresi dengan nilai p<0.001 dan
dinyatakan signifikan secara statistik (OR
1.5; CI 95%= 1.22 hingga 1.98; p<0.001).
Penelitian oleh Masdar Huriatul et
al., (2016) menunjukkan 17.4% subjek
penelitian mengalami depresi, 65.2%
mengalami kecemasan, dan 34,8% meng-
alami stres. Hasil penelitian tersebut me-
nunjukkan terdapat hubungan bermakna
antara depresi dengan obesitas dan stres
dengan obesitas.
2. Dampak obesitas dan berat
berlebih remaja pada citra tubuh
remaja.
Hasil analisis didapatkan bahwa obesitas
dan berat berlebih remaja berdampak se-
cara langsung pada citra tubuh secara
negatif.
Citra tubuh adalah penilaian sese-
orang terhadap dirinya untuk dihadapkan
atau ditunjukkan kepada orang lain. Citra
tubuh juga menggambarkan bagaimana
seseorang dapat memandang dirinya secara
positif atau negatif.
Bagi remaja yang mengalami obesitas
atau berat berlebih, masalah yang sering
kali muncul adalah kepercayaan diri.
Tubuh yang kurus dianggap menarik dan
simbol kecantikan. Anggapan tersebut
menumbuhkan percaya diri bagi remaja
berbadan kurus, namun sebaliknya dapat
menimbulkan krisis percaya diri pada
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remaja dengan obesitas atau berat berlebih.
Anggapan-anggapan tersebut pula dapat
menyebabkan remaja dengan obesitas atau
berat berlebih merasakan ketidakpuasan
terhadap dirinya. Pengalaman sosial negatif
yang terus berulang dapat terakumulasi
dari waktu ke waktu dan menghasilkan
hasil psikologis negatif seperti ketidak-
puasan tubuh yang lebih tinggi (Alleva et al,
2014).
Efek ini akan lebih terasa pada indi-
vidu yang selalu terpapar stigmatisasi ter-
kait berat badan dan bentuk tubuhnya.
Ketidakpuasan terhadap tubuh sendiri yang
akan berefek pada timbulnya konsep diri
atau citra tubuh yang negatif pada diri
remaja tersebut (McClanahan et al., 2009).
Penelitian dilakukan oleh Ozmen
Dilek et al., (2007) mengungkapkan hal
yang sama yaitu remaja dengan obesitas
dan berat berlebih menurut Indeks Massa
Tubuh memiliki hubungan yang signifikan
(p< 0.001) mempengaruhi citra tubuh dan
kepuasan terhadap tubuhnya. Nilai OR se-
besar 0.60 yang berarti remaja dengan
obesitas dan berat berlebih memiliki risiko
mengalami citra tubuh negatif 1.7 kali lebih
tinggi dibandingkan remaja dengan berat
badan normal.
3. Dampak obesitas dan berat
berlebih remaja pada penilaian
diri melalui citra tubuh.
Hasil analisis didapatkan bahwa obesitas
dan berat berlebih remaja berdampak se-
cara tidak langsung pada penilaian diri
melalui citra tubuh secara positif.
Penilaian diri merupakan keyakinan
diri seseorang akan kemampuan yang
dimilikinya. Banyak faktor yang dapat
mempengaruhi penilaian diri seseorang,
salah satunya adalah bagaimana individu
dapat mempersepsikan penampilan fisik-
nya. Ketika individu puas dan percaya diri
akan keadaan fisiknya, maka individu
111
Journal of Epidemiology and Public Health (2018), 3(2): 105-117
https://doi.org/10.26911/jepublichealth.2018.03.02.01
tersebut akan memiliki penilaian diri yang
tinggi, begitu pun sebaliknya.
Obesitas dan berat berlebih dapat
menyebabkan penilaian diri yang rendah
melalui tiga aspek, yaitu diskriminasi
sosial, rendahnya citra tubuh dan perasaan
bersalah dan malu akan tubuh yang
dimiliki.
Diskriminasi sosial masih kerap
dirasakan oleh individu berbadan gemuk.
Sebagian besar remaja gemuk mengalami
kesulitan dalam berteman atau mendekati
individu lawan jenis. Akibatnya individu
tersebut akan lebih mungkin mengalami
rendah diri.
Aspek kedua yaitu obesitas menye-
babkan penilaian diri rendah melalui citra
tubuh yang rendah. Obesitas dan berat
berlebih dapat menurunkan penilaian diri
melalui citra tubuhnya. Sebagian besar
LQGLYLGX REHVLWDV PHUDVD GLULQ\D ³MHOHN´
atau tidak menarik. Anggapan bahwa tubuh
gemuk diyakini sebagai kegagalan pribadi
karena menyimpang dari tubuh normal
yang ideal. Hal ini sangat mempengaruhi
kepercayaan diri mereka untuk berinteraksi
atau bersosialisasi dengan orang lain.
Akibatnya remaja dengan obesitas dan
berat berlebih dapat mengalami krisis
kepercayaan diri yang menyebabkan indi-
vidu tersebut mengalami penurunan
kepuasan dan keyakinan akan dirinya dan
berakibat pada penilaian dirinya yang
rendah (Klaczynski et al., 2004).
Selain itu, perasaan bersalah dan
malu akan tubuh yang dimiliki kerap kali
masih dirasakan oleh sebagian besar
individu yang berbadan gemuk. Individu
berbadan gemuk cenderung akan meng-
hindari aktivitas-aktivitas fisik seperti olah-
raga. Hal tersebut dikarenakan ketidak-
mampuan tubuhnya untuk berlari cepat,
keringat berlebih atau masalah kesehatan
lain terkait obesitas dan berat berlebih yang
dialaminya. Akibatnya, individu-individu
112
tersebut merasa kurang produktif dan
kurang bermanfaat dibandingkan dengan
teman sebayanya. Hal ini lah yang dapat
menimbulkan rasa bersalah dan rendah
diri.
Hasil yang sama dari penelitian
Alvani et al. (2016) menunjukkan bahwa
penilaian diri dan perbedaan jenis kelamin
berhubungan secara signifikan dengan
status berat badan dengan nilai (p= 0.02).
Siswa dengan status berat badan obesitas
dan berat berlebih memiliki penilaian diri
lebih rendah dibandingkan siswa dengan
berat badan normal. Penilaian diri yang
rendah lebih banyak ditemukan pada siswa
oebsitas dan berat berlebih dengan jenis
kelamin perempuan.
4. Dampak obesitas dan berat
berlebih pada gangguan makan
melalui depresi.
Hasil analisis didapatkan bahwa obesitas
dan berat berlebih remaja berdampak se-
cara tidak langsung pada gangguan makan
melalui depresi secara positif.
Obesitas atau berat berlebih dapat
mengakibatkan depresi secara mekanisme
biologis dan psikologis. Secara biologis,
obesitas atau berat berlebih dianggap se-
bagai suatu keadaan peradangan, karena
terbukti pada pengaktifan jalur inflamasi
dalam tubuh. Sedangkan peradangan itu
sendiri, berperan dalam terjadinya depresi.
Sumbu hipotalamus-hipofisis-adrenal
(sumbu HPA) dianggap berperan. Obesitas
melibatkan disregulasi sumbu HPA dan
diketahui disregulasi sumbu HPA terlibat
dalam terjadinya depresi (Pasquali dan
Vicennati, 2000). Selain itu, obesitas me-
libatkan peningkatan risiko diabetes melli-
tus dan peningkatan resistensi insulin yang
dapat menyebabkan perubahan pada otak
dan meningkatkan risiko depresi (Shoelson
et al, 2007).
Secara mekanisme psikologis, depresi
adalah respon emosional dengan ciri
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 Almasith et al./ Path Analysis on the Psychosocial Impact of Obesity
keputusasaan, motivasi berkurang, peng-
hargaan terhadap diri rendah, proses ber-
pikir yang lambat, retardasi psikomotor
serta gangguan-gangguan makan dan tidur.
Kelebihan berat badan hingga obesitas dan
persepsinya dapat meningkatkan tekanan
psikologis (Atlantis dan Ball, 2008). Se-
bagian masyarakat umum masih percaya
bahwa kurus merupakan wujud keindahan,
kecantikan sebagai penerimaan sosial dan
faktor sosiokultural. Hal tersebut mening-
katkan ketidakpuasan tubuh dan mengu-
rangi harga diri, yang merupakan faktor
risiko terjadinya depresi (Derenne dan
Beresin, 2014).
Lubis (2016) membuat kategori gejala
depresi menjadi simtom emosional, kog-
nitif, motivasional dan fisik. Gangguan
makan merupakan salah satu simtom ter-
jadinya depresi pada kategori emosional
dan fisik. Gejala emosional adalah per-
ubahan perasaan atau tingkah laku yang
merupakan akibat langsung dari keadaan
emosi yang meliputi penurunan mood,
pandangan negatif terhadap diri sendiri,
hilangnya respon yang menggembirakan
dan tidak lagi merasakan kepuasan. Gang-
guan makan sebagai simtom depresi secara
emosional berhubungan dengan hilangnya
kepuasan yaitu penurunan aktivitas kebu-
tuhan biologis seperti makan, minum dan
berhubungan seksual. Selain itu, gangguan
makan merupakan simtom depresi secara
fisik berupa kehilangan nafsu makan dan
gangguan tidur.
Hal ini berarti gangguan makan yang
terjadi telah diawali dengan keadaan
depresi pada individu tersebut atau dapat
dikatakan depresi memicu kejadian gang-
guan makan individu secara emosional dan
fisik.
Hasil yang sama ditunjukkan oleh
penelitian Dahlmann et al., (2015) bahwa
hasil perilaku makan dan gangguannya
pada remaja dan indeks massa tubuhnya
e-ISSN: 2549-0273 (online)
serta fungsi psikologis yang berbasis popu-
lasi di Jerman dengan jumlah peserta 771
peserta (420 perempuan dan 351 laki-laki).
Rentang usia pada 11-17 tahun. Hasil pene-
litian menunjukkan skor tinggi pada gang-
guan makan secara signifikan terjadi pada
remaja dengan kelebihan berat badan (OR=
1.58; CI 95%= 1.19 hingga 1.09; p= 0.001)
dan munculnya gejala depresi (p<0.001).
Gejala awal depresi menunjukkan hubung-
an yang signifikan dengan berat badan
berlebih dan obesitas pada masa muda
(OR= 1.13; CI 95%= 1.01 hingga 1.25; p=
0.002). Gejala gangguan makan yang tinggi
dan hubungan yang signifikan dengan kese-
hatan mental yang buruk pada kelebihan
berat badan selama masa muda. Remaja
obesitas yang megalami depresi harus
dipantau untuk kelainan makan yang
terjadi.
5. Dampak obesitas dan berat ber-
lebih remaja pada kualitas hidup
melalui kejadian depresi.
Hasil analisis didapatkan bahwa obesitas
dan berat berlebih remaja berdampak se-
cara tidak langsung pada kualitas hidup
melalui depresi secara negatif.
Arah paparan obesitas mengakibat-
kan depresi dapat dilihat secara biologis
dan psikologis. Secara biologis, obesitas
atau berat berlebih merupakan suatu
keadaan peradangan, karena penambahan
berat badan telah terbukti mengaktifkan
jalur inflamasi dalam tubuh. Sedangkan
peradangan itu sendiri, berperan dalam ter-
jadinya depresi. Sumbu hipotalamus-
hipofisi-adrenal (sumbu HPA) dianggap
berperan. Obesitas melibatkan disregulasi
sumbu HPA dan diketahui disregulasi
sumbu HPA terlibat dalam terjadinya
depresi (Pasquali dan Vicennati, 2000).
Selain itu, obesitas melibatkan peningkatan
risiko diabetes mellitus dan peningkatan
resistensi insulin yang dapat menyebabkan
113
Journal of Epidemiology and Public Health (2018), 3(2): 105-117
https://doi.org/10.26911/jepublichealth.2018.03.02.01
perubahan pada otak dan meningkatkan
risiko depresi (Shoelson et al., 2007).
Selain mekanisme biologis, kejadian
depresi yang disebabkan karena obesitas
dan berat berlebih pun dapat dijelaskan
secara mekanisme psikologis. Depresi
adalah respon emosional dengan ciri kepu-
tus-asaan, motivasi berkurang, pengharga-
an terhadap diri rendah, proses berpikir
yang lambat, retardasi psikomotor serta
gangguan-gangguan makan dan tidur.
Kelebihan berat badan hingga obesitas dan
persepsinya dapat meningkatkan tekanan
psikologis (Atlantis dan Ball, 2008).
Sebagian masyarakat umum masih
beranggapan dan percaya bahwa kurus
merupakan wujud keindahan, kecantikan
sebagai penerimaan sosial dan faktor
sosiokultural. Hal tersebut meningkatkan
ketidakpuasan tubuh dan mengurangi
harga diri, yang merupakan faktor risiko
terjadinya depresi. Pola makan dan gang-
guan makan yang terganggu serta meng-
alami sakit fisik sebagai konsekuensi
langsung obesitas, juga diketahui dapat
meningkatkan risiko depresi (Derenne dan
Beresin, 2014).
Depresi merupakan wujud dari gang-
guan mental dan emosi yang buruk.
Sedangkan cakupan kualitas hidup itu sen-
diri meliputi kesejahteraan secara emosi,
sosial dan fisik. Seorang individu yang
mengalami depresi diartikan bahwa indi-
vidu tersebut memiliki kesejahteraan yang
buruk secara emosi. Individu dengan
kesejahteraan buruk secara emosi jelas
akan menurunkan kualitas hidupnya,
dimana kesejahteraan emosi merupakan
salah satu aspek dalam penilaian kualitas
hidup seorang individu (Fabricatore et al,
2005).
Hasil yang sama ditunjukkan oleh
penelitian Morrison et al. (2015) bahwa
gejala depresi dievaluasi dengan menggu-
nakan kuesioner Depresi Kelas Epidemio-
114
logi untuk Anak-anak dan kualitas hidup
dengan PedsQL 4.0. Hasil analisis multi-
variat menunjukkan tingkat obesitas ber-
pengaruh pada kejadian depresi (OR= 1.1;
CI 95%= 1.0 hingga 1.2; p= 0.05) dan kua-
litas hidup yang rendah (p<0.001).
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_child_adolescent/topics/adolescen-
ce/development/en/. (Diakses 17 Juni
2017).
_____ (2016a). Adolescents: Health Risks
and Solutions. WHO Regional Offi-
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_____ (2016b). Obesity and Overweight.
WHO Regional Offices: Media Centre
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117
 children
Article
Psychosocial Factors and Obesity in Adolescence:
A Case-Control Study
Elisabeth K. Andrie 1, *, Marina Melissourgou 2 , Alexandros Gryparis 3 , Elpis Vlachopapadopoulou 4 ,
Stephanos Michalacos 4 , Anais Renouf 1 , Theodoros N. Sergentanis 1,5 , Flora Bacopoulou 6 , Kyriaki Karavanaki 7 ,
Maria Tsolia 8 and Artemis Tsitsika 1






Citation: Andrie, E.K.; Melissourgou,
M.; Gryparis, A.;
Vlachopapadopoulou, E.; Michalacos,
S.; Renouf, A.; Sergentanis, T.N.;
Bacopoulou, F.; Karavanaki, K.; Tsolia,
M.; et al. Psychosocial Factors and
Obesity in Adolescence: A
Case-Control Study. Children 2021, 8,
308. https://doi.org/10.3390/
children8040308
Academic Editor: Rachana Shah
Received: 21 December 2020
Accepted: 13 April 2021
Published: 18 April 2021
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
published maps and institutional affil-
iations.
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Children 2021, 8, 308. https://doi.org/10.3390/children8040308
1 MSc Program “Strategies of Developmental and Adolescent Health”, Second Department of Pediatrics,
P. & A. Kyriakou Children’s Hospital, School of Medicine, National and Kapodistrian University of Athens,
11527 Athens, Greece; anais.renouf@hotmail.com (A.R.); tsergentanis@yahoo.gr (T.N.S.);
info@youth-health.gr (A.T.)
2 Department of Endocrinology & Metabolism—Diabetology Center, Korgialenio Benakio—Hellenic Red Cross
General Hospital of Athens, 11526 Athens, Greece; melmarina2004@yahoo.gr
3 Department of Diabetes Mellitus and Metabolism, School of Medicine,
National and Kapodistrian University of Athens, Aretaieion Hospital, 11528 Athens, Greece;
al.grip@gmail.com
4 Department of Endocrinology, Growth and Development, P. & A. Kyriakou Children’s Hospital,
11527 Athens, Greece; elpis.vl@gmail.com (E.V.); stmichalakos@gmail.com (S.M.)
5 Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Alexandra Hospital,
School of Medicine, 11528 Athens, Greece
6 Center for Adolescent Medicine and UNESCO Chair on Adolescent Health Care,
First Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens,
Aghia Sophia Children’s Hospital, 11527 Athens, Greece; bacopouf@hotmail.com
7 Diabetes and Metabolism Clinic, Second Department of Pediatrics, School of Medicine,
National and Kapodistrian University of Athens, P. & A. Kyriakou Children’s Hospital,
11527 Athens, Greece; kkarav@yahoo.gr
8 Second Department of Pediatrics, School of Medicine, National and Kapodistrian University of Athens,
P. & A. Kyriakou Children’s Hospital, 1527 Athens, Greece; matsolia@med.uoa.gr
* Correspondence: andrie@sideris.de; Tel.: +30-210-771-0824
Abstract: Introduction: The continuously increasing prevalence of childhood obesity is reaching
epidemic proportions. Greece is among the countries with the highest childhood obesity prevalence
rates. The present study aims to identify psychosocial factors associated with excess body weight
of adolescents. Methods: This case-control study was conducted in Athens, Greece, and included
414 adolescents aged 11–18 years. Anthropometric measurements were recorded, and an anonymous
self-completed questionnaire captured the psychosocial background, family environment, peer
relations, and school environment. Results: Of the total sample of adolescents, 54.6% had normal
body weight and 45.4% were overweight or obese. A multivariate logistic regression analysis showed
that the factors related to the presence of overweight/obesity were adolescents’ age (OR = 0.416,
p < 0.001), area of residence, presence of anxiety (OR = 4.661, p = 0.001), presence of melancholia
(OR = 2.723, p = 0.016), participation in sports (OR = 0.088, p <0.001), smoking (OR = 0.185, p = 0.005),
and mother’s occupation (OR = 0.065, p < 0.001). Conclusion: Psychological problems, maternal
occupation, the absence of physical activity, and poor school performance were associated with
adolescent overweight/obesity. It is important that screening for the presence of psychosocial issues
is included in childhood obesity policies and treatment.
Keywords: adolescents; obesity; psychosocial factors; psychological stress; children’s environment
1. Introduction
Childhood and adolescent obesity is considered to be a major public health problem
of the 21st century that has reached epidemic proportions [1]. During the last decade,
https://www.mdpi.com/journal/children
Children 2021, 8, 308 2 of 11

its prevalence has increased, as the number of overweight and obese children has risen
dramatically from 4% in 1975 to 18% in 2016 [2]. In 2016, approximately 340 million
children and adolescents aged between five and 19 years old worldwide were diagnosed
with overweight or obesity [2]. Boys tend to be overweight or obese more frequently
than girls; among children and adolescents aged between five and 17 years, 22.9% of
boys and 21.4% of girls were overweight or obese in the countries of the Organization for
Economic Cooperation and Development (OECD) [3]. Greece, Italy, and Spain are among
the countries with the highest childhood obesity rates in Europe [4]. Previous research
documents the prevalence of overweight and obesity in Greek children, varying between
30–40% [5]. Other studies report rates of 37% for girls and 45% for boys for overweight or
obesity in Greece [3].
The etiology of obesity is multifactorial. Genetic and environmental factors in-
clude certain infections, lifestyle, and eating behaviors. [2,6,7]. Psychosocial issues may
also contribute to the development of obesity. During emotional or physical stress, the
hypothalamic–pituitary–adrenal (HPA) axis is activated, while dopamine may also be
involved [8]. Stress is associated with a change in eating behaviors; approximately 40% of
people increase their food intake in time of stress. During stress periods, highly palatable
foods, which are usually rich in sugar and fat, are consumed regardless of the presence of
hunger [9].
Children may develop psychological stress due to physical, emotional, or sexual abuse
as well as emotional or physical negligence [10]. Besides dysfunction within the family, lack
of friends, bullying, and the perception of non-integration in the neighborhood can also
lead to stress, depression, and low self-esteem [11]. Bullying is a type of aggression that
can take place in any human relationship. Examples of adolescents who may be targeted
are those who seem to be different from their peers because of their race, clothing, or
weight status, but also because of their anxiety, low self-esteem, or disabilities. Further-
more, discrepancies in regard to social level and parental income may trigger bullying
among peers [12]. Adolescents who are victims of bullying are at high risk for adverse
mental health outcomes, such as low self-esteem [13], depression, anxiety, and suicide [14].
Psychological trauma during childhood is one of the most significant predictors for the
development of obesity [15,16].
Although previous research documents the fact that childhood obesity is associated
with psychosocial problems [17], to our knowledge there are no published data addressing
the association between psychosocial factors and overweight/obesity in Greek adolescents.
The aim of the present study was to identify differences in the psychosocial background
between adolescents with normal weight and adolescents with overweight/obesity, as well
as associations of psychosocial issues with excess body weight, among adolescents visiting
a tertiary children’s hospital, in Athens, Greece.

2. Participants and Methods

This case-control study drew data from adolescents aged 11–18 years who attended
the tertiary “P. & A. Kyriakou” Children’s Hospital in Athens, Greece, in 2017 and 2018.
The group of cases was recruited from the Adolescent Health Unit (A.H.U.) of the Second
Department of Paediatrics of the “P. & A. Kyriakou” Children’s Hospital and consisted of
overweight or obese adolescents who approached the Unit for that issue as new clients. The
control group of adolescents with normal weight was recruited from outpatient services
of the same hospital. They were attending for mild conditions such as mild respiratory
conditions, gastrointestinal or genitourinary conditions, and various manifestations of
allergy that are not related to obesity. Adolescents with severe underlying medical con-
ditions, underweight or overweight adolescents, and those receiving chronic medication
were excluded from the control group. The recruitment of normal-weight adolescents
who attended the A.H.U. over the study period was avoided, as the majority of them had
underlying psychological issues and chronic medical conditions that had affected their
body weight.
Children 2021, 8, 308 3 of 11

Signed informed consent was obtained from the participating adolescents and their
parents or legal guardians. The study was approved by the “P & A Kyriakou” Children’s
Hospital Ethics Committee.

2.1. Data Collection Procedure

Findings from the clinical examination and anthropometric measurements of par-
ticipants were recorded. Height was measured using a SECA 217 stadiometer, weight
was measured with a Tanita Total Body Composition Analyzer TBF-410GS, and the body
mass index (BMI) was calculated. Participants’ BMI classification was carried out in accor-
dance with the International Obesity Task Force cut-off points for age and gender [18]. All
anthropometric measurements were carried out by pediatricians.
All participants completed the Achenbach Youth Self-Report questionnaire for children
and teenagers (11 to 18 years) to assess their psychological profiles. The Youth Self-
Report (YSR) is an instrument measuring psychosocial wellbeing as well as adolescents’
competence and problems in social, academic, cognitive, internalizing, and externalizing
behaviors [17]. It has been standardized for use in Greece [19].
Participants’ school performance was classified as follows:
Below the base: < 10 (for middle school and high school) or <5 (for primary school).
Below average: 10–14.5 (for middle school and high school) or 5–6 (for primary school).
Average: 14.5–16 (for middle school and high school) or 7–8 (for primary school).
Above average: 16–20 (for middle school and high school) or 9–10 (for primary school).
All measurements were recorded, and instruments were administered upon entry to
the study by staff who had received appropriate training.

2.2. Statistical Analysis

Variables that are normally distributed are presented as mean ± SD. Categorical
variables are presented as absolute and relative frequencies (%). In order to investigate
whether two categorical variables were related, Pearson’s chi-square test was used. The
Mann–Whitney U test was also used to compare the medians of two independent samples.
To investigate possible confounding by sex, the same analysis was performed stratified
by gender.
Multivariate logistic regression analysis was then performed to confirm which param-
eters were significantly associated with the presence of overweight or obesity. Results with
a two-sided p-value < 0.05 were considered statistically significant, whereas results with a
two-sided p-value between 0.05 and 0.10 were considered as suggestive. All statistical anal-
yses were performed using IBM SPSS v.23 (IBM Corp. Released2015. IBM SPSS Statistics
for Windows, Version 23.0, IBM Corp., Armonk, NY, USA) software.

3. Results
Initially, 573 adolescents were recruited, but 159 were subsequently excluded from the
analysis due to incomplete data.
Thus, a total of 414 adolescents with mean age (±SD) of 15.09 ± 1.81 years participated
in this study. Among them, 233 (56.3%) were girls and 181 (43.7%) were boys. The mean
weight (± SD) of the participants was 68.63 ± 16.57 kg, the mean height (±SD) was
1.67 ± 0.08 m, and the mean BMI (± SD) was 24.54 ± 5.56 kg/m2 . In terms of their BMI,
54.6% had a normal BMI, 20.3% were in the overweight range, and 25.1% were in the
obese range.
The demographic data of the participants, according to BMI categories, are shown in
Table 1. In the overweight–obese group, boys made up only one third of the overweight
but about half of the obese (p = 0.008). The average age (± SD) differed significantly
(p-value < 0.001) between participants with normal weight (15.8 ± 1.3) and adolescents
with overweight or obesity (14.3 ± 2.0). Regarding maternal occupation, household
status was reported for the majority (30.7%) of normal weight participants and “public
sector employee” for the majority (28.6%) of participants with overweight or obesity
Children 2021, 8, 308 4 of 11

(p = 0.009). Most of the participants (96.1%) lived in the Attica Region, and only 3.9% lived
in other areas of Greece; 38.9% of normal weight participants were living in the western
suburbs, while 35% of the overweight/obese adolescents lived in the center of Athens
(p-value < 0.001). The vast majority of adolescents were Greek (92.8%), while 29 (7.2%)
had other nationalities, mostly Albanian. Regarding parental marital status, 82.4% of the
participants with normal weight had married parents, while adolescents with overweight
or obesity exhibited lower rates (p = 0.007).

Table 1. Participants’ demographic data by weight status (normal weight, overweight/obese, overweight and obese sepa-
rately).

Overweight-
Normal Weight Obese Overweight Obese
Variables (N = 226) (N = 188) p-Value * (N = 84) (N = 104) p-Value *
Frequency (%) Frequency (%) Frequency (%)
Frequency (%)
Sex
Female 126 (55.8%) 107 (56.9%) 57 (67.9%) 50 (48.1%)
Male 100 (44.2%) 81 (43.1%) 0.812 27 (32.1%) 54 (51.9%) 0.008
Age
mean (±SD) 15.80 (±1.26) 14.26 (±2.00) <0.001 14.59 (±2.04) 13.98 (±1.94) 0.047
Siblings
0 30 (13.3%) 34 (20.5%) 15 (21.4%) 19 (19.8%)
1 144 (63.7%) 97 (58.4%) 39 (55.7%) 58 (60.4%)
2 32 (14.2%) 29 (17.5%) 11 (15.7%) 18 (18.8%)
3 13 (5.8%) 6 (3.6%) 0.033 5 (7.1%) 1 (1.0%) 0.518
4 4 (1.8%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
5 3 (1.3%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
Paternal occupation
Unemployed 5 (2.3%) 7 (3.9%) 3 (3.7%) 4 (4.1%)
Household 1 (0.5%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
Private sector
employee 79 (36.6%) 71 (39.4%) 0.866 32 (39%) 39 (39.8%) 0.836
Public sector employee 42 (19.4%) 34 (18.9%) 15 (18.3%) 19 (19.4%)
Self-employed 74 (34.3%) 58 (32.2%) 29 (35.4%) 29 (29.6%)
Retired 15 (69%) 10 (5.6%) 3 (3.7%) 7 (7.1%)
Maternal Occupation
Unemployed 6 (2.8%) 13 (7%) 4 (4.8%) 9 (8.8%)
Household 66 (30.7%) 32 (17.3%) 13 (15.7%) 19 (18.6%)
Private sector 0.009 0.552
employee 61 (28.4%) 52 (28.1%) 21 (25.3%) 31 (30.4%)
Public sector employee 53 (24.7%) 53 (28.6%) 27 (32.5%) 26 (25.5%)
Self-employed 27 (12.6%) 29 (15.7%) 16 (19.3%) 13 (12.7%)
Retired 2 (0.9%) 6 (3.2%) 2 (2.4%) 4 (3.9%)
Parental Marital Status
Married 183 (82.4%) 111 (68.9%) 48 (70.6%) 63 (67.7%)
Divorced 34 (15.3%) 45 (28%) 0.007 19 (27.9%) 26 (28%) 0.677
Death of a parent 5 (2.3%) 5 (3.1%) 1 (1.5%) 4 (4.3%)
Recidency Area
Athens Center 0 (0.0%) 65 (35.1%) 22 (26.8%) 43 (41.7%)
North Suburbs 0 (0.0%) 29 (15.7%) 14 (17.1%) 15 (14.6%)
South Suburbs 37 (16.4%) 22 (11.9%) 10 (12.2%) 12 (11.7%)
East Suburbs 25 (11.1%) 21 (11.4%) 13 (15.9%) 8 (7.8%)
<0.001 0.506
West Suburbs 88 (38.9%) 15 (8.1%) 7 (8.5%) 8 (7.8%)
Piraeus 64 (28.3%) 15 (8.1%) 7 (8.5%) 8 (7.8%)
Rest of Attica 11 (4.9%) 3 (1.6%) 1 (1.2%) 2 (1.9%)
Rest of Greece 1 (0.4%) 15 (8.1%) 8 (9.8%) 7 (6.8%)
Nationality
Greek 200 (90.1%) 176 (96.2%) 79 (97.5%) 97 (95.1%)
Albanian 15 (6.8%) 6 (3.3%) 2 (2.5%) 4 (3.9%)
Russian 2 (0.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
African countries 1 (0.5%) 0 (0.0%) 0.191 0 (0.0%) 0 (0.0%) 0.829
Other European 3 (1.4%) 1 (0.5%) 0 (0.0%) 1 (1.0%)
countries
Asian countries 1(0.5%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
* Statistical analysis was performed with the Chi-Square test.
Children 2021, 8, 308 5 of 11

Table 2 presents the psychosocial factors, in relation to BMI categories. Among

study participants, 245 (66.6%) suffered from anxiety, which was more pronounced in
the overweight/obese group (p < 0.001). Furthermore, 118 (32.6%) of the participants
had melancholic depression (with overweight/obese adolescents exhibiting higher rates,
p = 0.003), and 35 (9.6%) had suicidal behaviors. Additionally, 66 (18%) reported low
self-esteem, with normal weight adolescents exhibiting higher rates (p < 0.001). Concerning
bullying, 91 (25.3%) adolescents reported that they had been victims of bullying at least
once in their life.

Table 2. Participants’ psychosocial factors by weight status (normal weight, overweight/obese, overweight and obese sepa-
rately).

Overweight-
Normal Weight Overweight Obese
Obese
Variables (N = 226) p-Value * (N = 84) (N = 104) p-Value *
(N = 188)
Frequency (%) Frequency (%) Frequency (%)
Frequency (%)
Anxiety
Yes 116 (55.5%) 129 (81.1%) 56 (83.6%) 73 (79.3%)
<0.001 0.544
No 93 (44.5%) 30 (18.9%) 11 (16.4%) 19 (20.7%)
Melancholic
Depression
Yes 55 (26.3%) 63 (41.2%) 26 (42.6%) 37 (40.2%)
0.003 0.867
No 154 (73.7%) 90 (47.9%) 35 (57.4%) 55 (59.8%)
Suicidal
behavior
Yes 23 (11%) 12 (7.8%) 5 (8.1%) 7 (7.7%)
0.371 1.000
No 187 (89%) 141 (92.2%) 57 (91.9%) 84 (92.3%)
Low
self-esteem
Yes 57 (27%) 9 (5.8%) 3 (4.7%) 6 (6.5%)
<0.001 0.738
No 154 (73%) 147 (94.2%) 61 (95.3%) 86 (93.5%)
Bullying
Yes 57 (27%) 34 (22.8%) 9 (15%) 25 (28.1%)
0.391 0.074
No 154 (73%) 115 (77.2%) 51 (85%) 64 (71.9%)
* Statistical analysis was performed with the Chi-Square test.

The peer relations of the participants were also examined (Table 3). Among study
participants, 170 (45.7%) had already been in a romantic relationship and 89 (24.9%) had
complete sexual activity; significantly more adolescents with normal weight than those with
overweight/obesity (p < 0.001). Additionally, 294 (77.6%) participants were participating in
at least one sport activity, significantly more adolescents with normal weight (89.9%) than
those with overweight/obesity (61.1%, p-value < 0.001). Concerning school performance
(Table 4), most adolescents (281, 99.6%) were going to school, and only one (0.4%) did
not attend school. There was a statistically significant difference in school performance
between normal and overweight/obese adolescents (p < 0.001); although most of the
participants were above average, more normal-weight participants had average grade
(37.2%), while most participants with overweight or obesity (27.6%) were below average.
Moreover, normal-weight participants reported more unjustified absences (49%) compared
to adolescents with overweight or obesity (24.1%, p < 0.001).
Children 2021, 8, 308 6 of 11

Table 3. Participants’ activities by weight status (normal weight, overweight/obese, overweight and obese separately).

Overweight-
Normal Weight Overweight (N Obese
Obese
Variables (N = 226) p-Value * = 84) (N = 104) p-Value *
(N = 188)
Frequency (%) Frequency (%) Frequency (%)
Frequency (%)
Romantic
relationships
Yes 97 (51.6%) 73 (47.1%) 35 (53.8%) 38 (42.2%)
<0.001 0.192
No 91 (48.4%) 82 (52.9%) 30 (46.2) 52 (57.8%)
Sexual
relationships
Yes 75 (36.2%) 14 (9.3%) 7 (11.3%) 7 (8.0%)
<0.001 0.573
No 132 (63.8%) 136 (90.7%) 55 (88.7%) 81 (92%)
Sports activities
Yes 195 (89.9%) 99 (61.1%) 48 (69.6%) 51 (54.8%)
<0.001 0.073
No 22 (10.1%) 63 (38.9%) 21 (30.4%) 42 (45.2%)
Hobbies
Yes 195 (89.9%) 141 (92.2%) 59 (90.8%) 82 (93.2%)
0.473 0.762
No 22 (10.1%) 12 (7.8%) 6 (9.2%) 6 (6.8%)
* Statistical analysis was performed with the Chi-Square test.

Table 4. Participants’ school performance by weight status (normal weight, overweight/obese, overweight and obese separately).

Overweight-
Normal Weight Overweight (N Obese
Obese
Variables (N = 226) p-Value * = 84) (N = 104) p-Value *
(N = 188)
Frequency (%) Frequency (%) Frequency (%)
Frequency (%)
School
performance
Below the base 2 (1.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)
Below average 12 (5.8%) 37(27.6%) 9 (15.5%) 28 (36.8%)
<0.001 0.026
Average 77 (37.2%) 25(18.7%) 13 (22.4%) 12 (15.8%)
Above average 116 (56%) 72 (53.7%) 36 (62.1%) 36 (47.4%)
Unjustified
absences
Yes 102 (49.0%) 14 (24.1%) 6 (27.3%) 8 (22.2%)
0.001 0.756
No 106 (51.0%) 44 (75.9%) 16 (72.7%) 28 (77.8%)
* Statistical analysis was performed with the Chi-Square test.

When stratified by sex, similar results were found between normal weight and ado-
lescents with overweight or obesity for both girls and boys. Nevertheless, in terms of
parental marital status, a statistically significant difference was observed between normal
weight and boys with overweight or obesity (p = 0.006), which was not found in girls
(p-value = 0.103). Additionally, maternal occupation differed significantly between the two
BMI groups in girls (p = 0.045), with the majority (39.0%) of normal weight participants’
mothers being housewives and the majority of overweight/obese participants’ mothers
being employees in the public or private sectors (30.2%). No significant differences in
maternal occupation were found in boys according to their BMI (p = 0.187). Finally, in terms
of school performance, statistically significantly more unjustified absences were reported
by normal-weight girls vs. girls with overweight or obesity (42.5% vs 12.5% respectively,
p = 0.002). No significant differences in unjustified absences in boys according to their BMI
were observed.
A multivariate logistic regression analysis (Table 5) showed that the factors statistically
related to the presence of overweight/obesity were younger age (OR = 0.416, p < 0.001),
area of residence, presence of anxiety (OR = 4.661, p = 0.001) or melancholic depression
(OR = 2.723, p = 0.016), sport’s activities (OR = 0.088, p < 0.001), smoking (OR = 0.185,
Children 2021, 8, 308 7 of 11

p = 0.005), and maternal occupation (OR = 0.065, p < 0.001). Other parameters that were
included in the model but were not related significantly to the presence of obesity were
parental occupation, ethnicity, bullying, number of siblings, and romantic or sexual rela-
tionships.

Table 5. Multivariate logistic regression results.

95% C.I. for OR

Variables OR p-Value
Lower Upper
Participants’ age a 0.416 <0.001 0.312 0.555
Sports activities Yes a 0.088 <0.001 0.035 0.220
Residency area a
West suburbs 0.062 <0.001 0.021 0.181
Piraeus 0.089 <0.001 0.032 0.248
Rest of Attica/Greece 1.084 0.899 0.314 3.737
Anxiety a 4.661 0.001 1.837 11.829
Maternal occupation a

Housewife 0.065 0.001 0.012 0.344

Working 0.261 0.261 0.060 1.128
Retired 0.479 0.620 0.026
a
Smoking Yes 0.185 0.005 0.058 0.594
Melancholic
2.723 0.016 1.210 6.132
Depressiona
Hobbies? a Yes 0.488 0.259 0.140 1.698
Sex a

Boys 1.571 0.261 0.714 3.454

Parental marital status a
Married 0.764 0.536 0.326 1.790
Siblings a 0.366 0.647 0.251 1.665
aReference levels; Sex: Girls; Parental marital status: Divorced/Death of a parent; Residency area: Center of
Athens/North suburbs/South suburbs/East suburbs; Siblings: No; Sports: No; Smoking: No; Hobbies: No;
Maternal occupation: Unemployed.

4. Discussion
The prevalence of childhood overweight and obesity is increasing rapidly worldwide
and is recognized as a leading threat to public health. The present study examined the psy-
chosocial correlates of obesity in adolescents in Greece. Statistically significant differences
between overweight/obese cases and controls were observed in terms of sex, maternal
employment, parental marital status, anxiety, melancholic depression, low self-esteem,
romantic and sexual relationships, sports, school performance, and school absenteeism.
In the present study, maternal employment was significantly associated with ado-
lescents’ obesity. Thus, in the normal weight group, most mothers were unemployed,
while in the overweight/obese group most of them were public sector employees. On
the other hand, no relation between overweight/obesity and paternal employment was
observed. Our results concerning mothers’ employment status are consistent with sev-
eral studies [20–25] that have linked maternal employment to children’s and adolescents’
obesity. In addition, Anderson et al. observed that the more hours the mothers worked,
the higher the risk for the children to become overweight or obese [25]. Nevertheless, the
mechanisms that mediate these associations remain largely unknown. The main channels
associated with greater weight include less time allocated to housework (including meal
Children 2021, 8, 308 8 of 11

preparation) and a reduction in maternal supervision regarding children’s food intake and
physical activity [26–28]. The present study showed that a significantly higher percent-
age (28%) of overweight and obese adolescents than normal-weight participants (15.3%)
had divorced parents. The GENDAI study carried out in Greece confirmed that parental
marital status plays a key role in the emergence of obesity in adolescents [28]. This was
confirmed not only in Greece, where traditional family status is more frequent, but also
in studies from other European countries, such as Poland, the United Kingdom, Iceland,
and Sweden [20,29–32], indicating that a stable family environment is important for the
preservation of normal body weight [33]. Research has indicated that children of single
parents are less likely to eat at the table together with the parent and are allowed to play
and watch television during meals [34]. Children of single-parent households are reported
to consume more total fat, saturated fat, and sweetened beverages and also watch televi-
sion/video for more than two hours daily more frequently when compared to children
of two-parent family households [35]. On the other hand, a similar study from Nordic
countries did not confirm our results [31].
In the present study, anxiety was also linked to higher BMI in both genders. This result
confirmed the findings of previous studies [25,36,37] that revealed a gender difference in the
link between anxiety and the development of obesity. In particular, most of them identified
a stronger link between the development of overweight and obesity due to anxiety in
girls [25,36]. Separation anxiety was associated with increased waist circumference and
BMI in boys, whereas in girls, somatic symptoms of anxiety were associated with waist
circumference and higher body fat [25].
Previous research has demonstrated associations between obesity and depression
in children and adolescents [38]. Nevertheless, the mental well-being and psychiatric
health of children and adolescents suffering from obesity are the subject of consider-
able debate [25,36,39–45]. There are two systematic reviews and a meta-analysis on this
topic [37,45,46] suggesting that obese children and adolescents are more likely to suffer
from depression and depressive symptoms, with females being at higher risk. Consistent
with previous reports, our study indicated that melancholic depression was related to
overweight/obesity in adolescents [25,40,41,47,48]. There are three possible pathways
that could account for these disorders. Obesity could lead to depression through weight
stigma [49], poor self-esteem [50], and/or reduced mobility and ability to engage in activi-
ties [51]. Depression could lead to obesity directly through the occurrence of depressive
symptoms (e.g., increased appetite, poor sleep, lethargy resulting in decreased calorie
expenditure, and/or reduced energy to obtain and cook healthy foods), antidepressant
medication side effects, or attempts to self-medicate depressive feelings with unhealthy
foods [51–53]. Further investigation of the mechanisms underlying the observed comorbid-
ity is needed.
We found that the frequency of participation in sport activities was significantly
higher in normal-weight than overweight/ obese adolescents. This is expected and has
also been demonstrated in previous studies, as a lack of physical activity in adolescence
has been found to lead to obesity [54,55]. There is a bidirectional effect between the lack
of physical activity and increased BMI, as the lack of physical activity may lead to an
increase in BMI, but inversely, an increased BMI may lead to reduced participation in sport
activities [55]. In addition, adolescents may also be more self-conscious about their physical
appearance and thus refrain from exercising in front of others [56]. In this survey, apart
from assessing the frequency of physical activity among adolescents, we also found that
those who were socially integrated and participated in team sports had a lower probability
of being overweight because of higher self-esteem and better relationships with their peers.
In our study, both school performance and unjustified absences were associated
with overweight/obesity. To our knowledge, there is no similar research identifying a
link between school truancy and development of overweight/obesity. In addition, poor
school performance may be related to obesity. Poor school performance is associated with
Children 2021, 8, 308 9 of 11

negative feelings of failure and inability to succeed. These in turn are related to depressive
symptoms, worrying about school results, and overeating [57].
To our knowledge, this is the first study to examine whether psychosocial factors are
associated with increased prevalence of overweight and obesity among Greek adolescents.
One limitation of the study is the relatively small sample, which in addition is not repre-
sentative of the population of all of Greece, as it is restricted to adolescents living in the
Attica Region, although this does represent 35% of the country’s population.
In conclusion, this study showed that psychological problems, such as anxiety and
melancholic depression, are associated with obesity. Moreover, maternal occupation, the
absence of physical activity, and poor school performance were associated with adolescent
overweight/obesity. Therefore, it is of great importance that screening for the presence of
psychosocial issues should be included in childhood obesity policies and proper handling
of these issues should be provided. In addition, public health policies should be formulated
and strengthened in the future targeting physical activity, maternal employment, and work
schedules early in adolescence, with special attention to girls.

Author Contributions: Conceptualization: A.T.; methodology: A.G.; validation: T.N.S.; formal

analysis: A.G.; investigation: A.R.; resources: M.M.; data curation: A.R.; writing—original draft
preparation: E.K.A. and M.M.; writing—review and editing: E.K.A., E.V., S.M., F.B., and K.K.;
supervision: M.T.; project administration: A.T. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki, and approved by “P & A Kyriakou” Children’s Hospital Ethics Committee
(11885/4-7-2019).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Acknowledgments: We would like to thank the adolescents and their guardians who participated in
this study for their valuable contribution.
Conflicts of Interest: The authors declare no conflict of interest.

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 International Journal of
Environmental Research
and Public Health

Article
Increased Prevalence of Psychosocial, Behavioral, and
Socio-Environmental Risk Factors among Overweight
and Obese Youths in Mexico and the United States
Yvonne N. Flores 1,2 , Zuelma A. Contreras 3 , Paula Ramírez-Palacios 1, * , Leo S. Morales 4 ,
Todd C. Edwards 4 , Katia Gallegos-Carrillo 1 , Jorge Salmerón 5 , Cathy M. Lang 6 ,
Noémie Sportiche 1 and Donald L. Patrick 4
1 Unidad de Investigación Epidemiológica y en Servicios de Salud, Delegación Morelos, Instituto Mexicano
del Seguro Social, Cuernavaca, Morelos 62000, Mexico; ynflores@ucla.edu (Y.N.F.);
kgallegosc13@gmail.com (K.G.-C.); nsportiche@gmail.com (N.S.)
2 UCLA Department of Health Policy and Management, Center for Cancer Prevention and Control Research,
Fielding School of Public Health and Jonsson Comprehensive Cancer Center, Los Angeles, CA 90095, USA
3 UCLA Department of Epidemiology, Fielding School of Public Health, Los Angeles, CA 90095, USA;
zuelmaarellano@ucla.edu
4 Department of Health Services, School of Public Health, University of Washington, Seattle, WA 98195, USA;
lsm2010@uw.edu (L.S.M.); toddce.uw@gmail.com (T.C.E.); donald@uw.edu (D.L.P.)
5 Universidad Nacional Autónoma de México, Centro de Investigación en Políticas, Población y Salud.
Ciudad Universitaria, Ciudad de México 04510, Mexico; jorge.salmec@gmail.com
6 UCLA Department of Community Health Sciences, Fielding School of Public Health, Los Angeles, CA 90095,
USA; clang@ucla.edu
* Correspondence: paula_rzps@hotmail.com; Tel.: +52-777-100-1364




Received: 29 January 2019; Accepted: 27 April 2019; Published: 30 April 2019


Abstract: The aim of this study was to examine various psychosocial, behavioral, and
socio-environmental factors in a multiethnic sample of healthy-weight, overweight, and obese
youths in the United States (US) and Mexico and determine differences by sex. We conducted a
cross-sectional analysis of 633 youths aged 11–18 years who completed a self-reported questionnaire.
Height and weight were measured to determine body mass index (BMI). Overweight and obese
youth in both countries were significantly more likely to report a higher body image dissatisfaction
(Odds Ratio (OR) = 1.67 and OR= 2.95, respectively), depressive symptoms (OR = 1.08 and OR = 1.12,
respectively), perceive themselves as overweight (OR = 2.57) or obese (OR = 5.30), and a lower
weight-specific quality of life (OR = 0.97 and OR = 0.95, respectively) than healthy-weight youth.
Obese youth have lower healthy lifestyle priorities (OR = 0.75) and are less likely to be physically
active (OR = 0.79) and eat breakfast (OR = 0.47) than healthy-weight youth. Additionally, overweight
and obese youth are more likely to engage in weight control behaviors (OR = 5.19 and OR = 8.88,
respectively) and restrained eating than healthy-weight youth. All the aforementioned results had
a p-value of <0.05, which was considered statistically significant. The association between these
factors and overweight or obesity remained significant after controlling for age, sex, race/ethnicity,
and country. In conclusion, obesity was associated with a range of psychosocial, behavioral, and
socio-environmental risk factors in both countries. Our findings support the need for multifactorial
approaches when developing interventions to address the growing problem of obesity among youth
in the US and Mexico.

Keywords: obesity; quality of life; adolescent; risk factors; psychosocial; socio-environmental;

behavior; United States; Mexico; Latinos

Int. J. Environ. Res. Public Health 2019, 16, 1534; doi:10.3390/ijerph16091534 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019, 16, 1534 2 of 15

1. Introduction
The high prevalence of obesity among youth is one of the most concerning public health issues in
both developed and developing countries [1]. Most overweight or obese children live in developing
countries, where the rate of increase is over 30% higher than in more developed countries [1]. In the
past 40 years, the number of obese children and adolescents (aged five to 19 years) has increased from
11 million in 1975 to 124 million in 2016 [2]. If current trends continue, by 2022, there will be more obese
children and adolescents worldwide than moderately or severely underweight children [2]. Childhood
and adolescent overweight and obesity are associated with increased risk of subsequent diabetes,
stroke, coronary heart disease, hypertension, functional disability, as well as premature adult mortality
and morbidity [3,4]. In the United States (US), an estimated 34.5% of adolescents aged 12–19 years
were overweight or obese from 2011–2012, and of these, 16.9% were obese [5]. This number rose to
20.6% in 2015–2016 [6]. Disparities in obesity and overweight exist across racial and ethnic groups in
the US, with African American and Mexican-American adolescents ranking highest in prevalence [7,8].
During 2011–2012, the prevalence of overweight and obesity was 39.8% and 38.1% among African
American and Latino adolescents, respectively, followed by non-Latino white (31.2%) and Asian
(24.6%) adolescents [5]. From 2013–2016, the prevalence of obesity among youth of Mexican origin
aged 12–19 years was 26.6%, as compared to 17.2% among non-Latino whites [9]. Studies have also
shown that US-born Mexicans are significantly more likely to be overweight or obese than Mexican
immigrants [10,11]. In Mexico, the prevalence of obesity and overweight among adolescents aged
12–19 years was 36.3% in 2016 [12].
Addressing obesity is complex, due to its multi-causal nature that includes various psychosocial,
behavioral, and socio-environmental factors. Previous studies have found an association between
a range of psychosocial factors and increased obesity risk, such as body size dissatisfaction and
self-perception of overweight, because they may promote unhealthy weight control behaviors [13–15].
Other psychosocial factors that have been examined include exposure to adverse life events and the
influence of the family and peer environment, which may be associated with a greater risk of childhood
overweight/obesity [16]. Studies have also found that depressive symptoms are a risk factor for obesity
because binge eating may be used as a coping mechanism [14,17]. Obese youth report having a lower
quality of life (QOL) [18–20], which improves when they lose weight [21].
Unhealthy weight control and dietary restraint behaviors have been found to predict the onset
of obesity [14,15,17,22]. Studies also show that prioritizing healthy eating may protect youth
from becoming overweight or obese [23,24], whereas prioritizing physical activity appears to be
less protective [23]. Various studies have demonstrated a negative association between breakfast
consumption and an increase in body mass index (BMI) [14,22,25–27], which could be due to its
association with favorable nutrient intake, improved food choices, and higher physical activity
levels [26,28]. The protective effect of physical activity has also been observed in both cross-sectional
and longitudinal studies [14,22]. However, the relationship between fast food consumption and obesity
has not been established conclusively in the literature. Some studies have shown an inverse association
between fast food consumption and obesity [14,27], while others report that fast food consumption is a
predictor of weight gain [28,29].
Several socio-environmental factors have also been associated with risk of obesity in adolescents.
Parents who have unhealthy lifestyles are more likely to have children who become overweight or
obese [30–32]. Conversely, positive parental influence regarding healthy diet and frequent physical
activity have been associated with reductions in BMI among overweight and obese adolescents [33].
Studies also report that increased availability of healthy food at home encourages healthy eating
in adolescents and is protective against overweight and obesity [34,35], while parental obesity is
associated with an increased risk of adolescent and ensuing adult obesity [17]. However, Haines et al.
found that the availability of healthy food at home and perceived parental obesity did not predict onset
of obesity [14]. Parental concern regarding their child’s weight has been positively associated with their
child being overweight or obese [14,36]. Parental concern may lead to parental pressure to lose weight
Int. J. Environ. Res. Public Health 2019, 16, 1534 3 of 15

and encouragement of restrictive feeding practices, which could lead to weight gain [14,36]. However,
parents who reported being concerned about their child’s weight were more likely to improve the
family’s diet, limit child screen time, and attempt to increase their child’s physical activity levels [36].
Although there is no individual factor that causes obesity, most research to date has lacked an
integrated approach to examine the factors that may be contributing to the high rates of overweight and
obesity among youth [17]. An exception would be a study by Haines et al., which looked at the effects
of personal, behavioral, and socio-environmental factors on risk of overweight in an ethnically diverse
population in Minnesota [14]. To the best of our knowledge, the present study is the first to compare
the effects of multiple domains on overweight or obesity risk among a bi-national, ethnically diverse
sample of youth. The objective of this study was to identify risk and protective factors for overweight
or obesity within the following three domains: Psychosocial, behavioral, and socio-environmental, in a
sample of African American, Caucasian, and Latino youths in the US, and Mexican youths in Mexico,
and determine differences by sex.

2. Research Methods and Procedures

2.1. Study Population and Data Collection Procedures

US participants were recruited from community centers, schools, clinics, and youth programs in
Seattle, Washington and Los Angeles, California (n = 452). A convenience sample of youth was also
recruited from the main Mexican Institute of Social Security (IMSS, as per its Spanish abbreviation)
hospital in Cuernavaca, Morelos (n = 181). Study flyers were posted in various areas of the IMSS clinic,
and potential participants were also informed of the study by staff during their visit to the primary care
clinics. All individuals who expressed an interest in the study were contacted by a study recruiter who
conducted a telephone interview with the primary caregivers of the potential participants to determine
eligibility. Participants had to be African American, Caucasian, or Latino, and between the age of
11–18 years. Youths who met study inclusion criteria of age, 5th grade reading ability, and no serious
physical or mental illness diagnosis were informed that participation in the study would involve
completing a 40-min questionnaire and having their weight, height, and waist circumference measured.
All study participants were enrolled between 2006 and 2008, and informed consent was obtained from
each participant and a parent or guardian prior to their inclusion in the study. Further details regarding
study design, methodology, and baseline participant characteristics are specified elsewhere [19,37,38].
The Institutional Review Boards of the University of Washington, the University of California, Los
Angeles, and the Mexican Institute of Social Security approved all study materials including the study
questionnaire, protocol, and consent forms (Seattle Children’s Hospital IRB approval number: 11916;
IMSS IRB approval number: R-2007-1701-13; UCLA IRB approval number: G06-09-094-01).
Study participants completed a self-administered questionnaire that included the 21-item youth
quality of life weight-specific measure (YQOL-W), a generic youth quality of life Instrument (YQOL-R),
as well as measures of perceived general health, physical function, body shape satisfaction, and
symptoms of depression. The Spanish versions of these measures have been used extensively and
validated in other research studies [21,38–44]. All study materials were designed to be readable and
understandable at a 5th grade level.

2.2. Study Measures

The following study variables are all reported as indices except for physical activity, which was
measured with a single item. Each index score was derived by summing the individual item scores and
dividing by the number of items, with the exception of specific scales that have been established and
validated (e.g., the YQOL-W, CDI-S, and DEBQ) [19,21,39,45]. The Cronbach’s alpha value indicates
the internal consistency of each index that was created.
Int. J. Environ. Res. Public Health 2019, 16, 1534 4 of 15

2.2.1. Psychosocial Factors

Body image dissatisfaction. The body image satisfaction scale consists of the following three
questions that ask youth to rate their satisfaction with their weight, body shape, and muscle size [46]:
How satisfied are you with your weight?; How satisfied are you with your body shape?; How satisfied
are you with your muscle size? A body image dissatisfaction index was created using these questions,
which ranges from 1 to 5, with higher values indicating greater dissatisfaction (Cronbach’s α = 0.84).
Depression symptoms. The children’s depression inventory: short version (CDI-S) was used to
assess depressive symptoms [39]. The CDI-S consists of 10 items with a total score that ranges from 0
to 20. Higher scores indicate a greater presence of depressive symptoms [39].
Self-perception regarding weight. This index comprises three items with a total score ranging
from 1 to 5 (Cronbach’s α = 0.77). A higher score indicates a greater likelihood to regard oneself as
overweight or obese. One of the three items is the pictorial body image assessment (PBIA), which
asks youth: Which figure in A (female figures) or B (male figures) above is closest to your usual
weight? [38] The PBIA silhouettes were modified from Stunkard et al. [47] to include larger body
shapes. The silhouettes range from underweight (BMI < 19) to highly severe obesity (BMI > 50) [48].
The two other items ask youth to describe their weight (How do you describe your weight?) [49] and if
they ever feel fat (Do you ever feel fat?) [50].
Youth weight-specific quality of life. Weight-specific QOL was evaluated using the YQOL-W,
a 21-item instrument with three domain scores: Self, social, and environmental (Cronbach’s α for
selfitems = 0.90; Cronbach’s α for social items = 0.90; Cronbach’s α for environmental items = 0.90).
The validity and reliability of this instrument has been tested in a multicultural sample of overweight
and obese youth in the US and Mexico [19,21]. The YQOL-W has good reliability and validity for
assessing weight-specific QOL in children and adolescents, including one-week test–retest intra-class
correlation coefficients that were 0.73 for social, 0.71 for self, and 0.73 for environment [19]. The total
score for this survey ranges from 0–100, and 100 indicates the best QOL.

2.2.2. Behavioral Factors

Healthy lifestyle priorities. Youth were asked to indicate how much they care about (1) eating
healthy food and (2) staying fit and exercising [34]. The following two items: How much do you care
about eating healthy food? and How much do you care about staying fit and exercising? were used to
construct an index that ranges from 1 to 4, with 4 being the highest level of interest in maintaining a
healthy lifestyle (Cronbach’s α = 0.59).
Physically active. Physical activity was assessed with a single item that asks youth to rate their
physical activity level compared to others their age. Compared with most boys/girls your age, would
you say that you are: (3) More active, (2) less active, (1) about the same, (0) not sure? The response for
this item is on a 0–3 point scale, with a higher score indicating that youth consider themselves to be
more physically active than their peers [51].
Fast food consumption. An index was constructed using three items: During the past 7 days, how
many times did you eat French fries, sweets, chips, or other foods sometimes called “junk food”? How
many times in the past 7 days did you eat breakfast, lunch, or dinner from a “fast food” restaurant?
and We have “junk food” in my home. A 1 to 5 scale was used, with higher scores suggesting a higher
consumption of fast foods (Cronbach’s α = 0.73) [34].
Eats breakfast. A breakfast index was created using two items to classify respondents as having
eaten breakfast or not based on a yes–no response (1 = no, 2 = yes): Did you eat breakfast today? and I
ate breakfast at home. (Cronbach’s α = 0.58) [34,52].
Weight control behaviors. Participants were asked if they engaged in any of the following weight
control behaviors in the past 30 days to lose or keep from gaining weight: (1) Exercise, (2) eating
less food, fewer calories, or low-fat foods, (3) fasting, (4) taking diet pills, powders, or liquids [49,52].
A weight control index was created using the following four items based on yes–no responses (1 = no,
2 = yes): During the past 30 days, did you exercise to lose weight or keep from gaining weight?; During
Int. J. Environ. Res. Public Health 2019, 16, 1534 5 of 15

the past 30 days, did you eat less food, fewer calories, or foods low in fat to lose weight or keep from
gaining weight?; During the past 30 days, did you go without eating for 24 h or more (also called
fasting) to lose weight or to keep from gaining weight?; and During the past 30 days, did you take any
diet pills, powders, or liquids without a doctor’s advice to lose weight or to keep from gaining weight?
(Cronbach’s α = 0.37).
Restrained eating behaviors. Ten items from the Dutch eating behavior questionnaire (DEBQ)
were used to assess restrained eating behaviors [45]. The index score ranges from 1 to 5, with 5
indicating a higher frequency of restrained eating practices.

2.2.3. Socio-Environmental Factors

Perceived parental concern regarding adolescent weight. Youths’ perception of their parents’
concern regarding their weight and if they are getting sufficient physical activity was assessed with
a two-item index on a 5-point scale, where 5 is the highest level of perceived parental concern.
The following two items were used: How concerned are your parents about you becoming overweight?
and How concerned are your parents about you not getting enough physical activity? (Cronbach’s
α = 0.75) [34].
Perceived parent body size. Two indices that represent how youth perceive their parents’ body
size were constructed using images of the PBIA, one for males and the other for females. Participants
were asked to select the figure that is closest to the usual adult weight of their mother and father:
Which number under the figures in the figure Box A is closest to the usual adult weight of your mother?
and Which number under the figures in the figure Box B is closest to the usual adult weight of your
father? The PBIA silhouettes were modified from Stunkard et al. [47] to include larger body shapes.
The silhouettes range from underweight (BMI <19) to highly severe obesity (BMI >50) [48]. The 13-point
response scale for each item depicts a spectrum of silhouettes with 1 representing underweight, and
13 representing extremely obese (Cronbach’s α = 0.47) [38].
Mother/father healthy values. Perception of parent healthy values was evaluated using two items
that ask how concerned your parents are about (1) staying fit and exercising and (2) losing weight or
preventing weight gain: How much does your mother/father feel about staying fit and exercising (for
herself/himself)? and How much does your mother feel about losing weight or keeping from gaining
weight (for herself/himself)? Separate indices were constructed for mother and father health values,
with each consisting of these two items (Cronbach’s α = 0.73, 0.83, respectively). The response scale for
these indices ranges from 1 to 4, with 4 as the highest level of concern [34].
Home availability of healthy foods. An index of fruit and vegetable availability in the home was
created using two items that range from 1 to 4, with 4 indicating the highest frequency of healthy food
availability in the home: Fruits and vegetables are available in my home . . . (1) Never, (2) Sometimes,
(3) Usually, (4) Always, and Vegetables are served at dinner in my home . . . (1) Never, (2) Sometimes,
(3) Usually, (4) Always. (Cronbach’s α =0.69) [34].

2.2.4. Body Mass Index (BMI)

Height, weight, and waist circumference were measured by trained study staff. Participants were
weighed to the nearest 0.1 kg while wearing minimal clothing using a calibrated electronic TANITA
scale (model BC533; Tokyo, Japan). Height was determined to the nearest 0.1 cm using a conventional
stadiometer, with the youth standing barefoot, with their shoulders in a normal position. BMI was
determined to categorize participants as healthy-weight, overweight, or obese, based on the World
Health Organization (WHO) age- and sex-specific classifications for youth aged 5 to 19 years [53].

2.3. Statistical Analysis

A descriptive analysis of various sociodemographic variables was conducted for the total study
population by country of residence and BMI status. Psychosocial, behavioral, and socio-environmental
factors were also examined by country of residence and BMI status. Differences between proportions
Int. J. Environ. Res. Public Health 2019, 16, 1534 6 of 15

were assessed using chi-square tests of homogeneity, and t-tests were used to calculate differences
between means. Test for trend p-values were calculated to determine whether there was a linear
association between the study variables and BMI status. Odds ratios and 95% confidence intervals
for the association between psychosocial, behavioral, and socio-environmental factors and being
overweight or obese were calculated using multinomial logistic regression. These results were adjusted
for sex, age, race/ethnicity, and country of residence. Standardized odds ratios were determined to
facilitate comparisons of the study variables since their score range varied considerably. Standardized
odds ratios improve comparison and interpretability of the logistic regression results. Multinomial
logistic regression models for males and females were also used to examine any differences by sex,
after adjusting for age, race/ethnicity, and country. All p-values presented are 2-tailed and a p-value of
<0.05 was considered statistically significant. All statistical analyses were performed using STATA
software, version 12.0 (StataCorp LP, College Station, TX, USA).

3. Results
The sociodemographic characteristics of the study sample are compared by BMI status in Table 1.
Of the 633 participants, 54% are 11–14 years of age, 46% are between 15 and 18 years old, 52% are
female, 22% are African American, 25% are Caucasian, 24% are US Latinos, and 29% are youth who
live in Mexico. Thirty percent of youth have a healthy BMI, 30% are overweight, and 40% are obese.
Thirty-seven percent of participants are from Seattle, WA, 35% are from Los Angeles, CA, and 29% are
from Cuernavaca, Mexico. Chi-square tests were used to assess differences by weight status for each of
the study variables, separately by country. There are no significant differences by country of residence
in terms of sociodemographic characteristics for each of the three BMI categories, except for education
level among the US participants. (Table 1)

Table 1. Sample characteristics by body mass index (BMI) categories and country (n = 633).

Mexico (n = 181) United States (n = 452)

Sociodemographic Healthy Overweight Obese p-Value 1 Healthy Overweight Obese p-Value 1
Variables n = 43 n = 68 n = 70 n = 143 n = 124 n = 185
n (%) n (%) n (%) n (%) n (%) n (%)
Age (years)
11–14 20 (46.5) 43 (63.2) 40 (57.1) 73 (51.1) 67 (54.0) 98 (53.0)
0.222 0.883
15–18 23 (53.5) 25 (36.8) 30 (42.9) 70 (49.0) 57 (46.0) 87 (47.0)
Gender
Female 19 (44.2) 35 (51.5) 34 (48.6) 77 (53.9) 66 (53.2) 96 (51.9)
0.756 0.936
Male 24 (55.8) 33 (48.5) 36 (51.4) 66 (46.1) 58 (46.8) 89 (48.1)
Race/ethnicity
African American - - - 46 (32.2) 35 (28.2) 59 (31.9)
Caucasian - - - 0.451 53 (37.1) 42 (33.9) 65 (35.1) 0.798
Latino 43 (100.0) 68 (100.0) 70 (100.0) 44 (30.1) 47 (37.9) 61 (33.0)
Education Level
Elementary School (≤6th grade) 5 (11.6) 15 (22.1) 14 (20.0) 24 (16.8) 16 (12.9) 19 (10.3)
Middle School (7th–9th grade) 18 (41.9) 32 (47.1) 36 (51.4) 28 (19.6) 43 (34.7) 81 (43.58)
0.336 <0.001
High School (≥10th grade) 20 (46.5) 20 (29.4) 20 (28.6) 41 (28.7) 35 (28.2) 57 (30.8)
Missing - 1 (1.5) - 50 (35.0) 30 (24.2) 28 (15.1)
Mother’s Education
Less than High School 26 (60.5) 36 (52.9) 44 (62.9) 28 (19.6) 17 (13.7) 31 (16.7)
High School/GED 14 (32.6) 22 (32.4) 17 (24.3) 22 (15.4) 20 (16.1) 37 (20.0)
Some college 1 (2.3) 2 (2.9) 2 (2.9) 38 (26.6) 42 (33.9) 52 (28.1)
0.818 0.886
University or higher 2 (4.7) 7 (10.3) 7 (10.0) 46 (32.2) 39 (31.5) 54 (29.2)
Don’t know - 1 (1.5) - 4 (2.8) 2 (1.6) 3 (1.6)
Missing - - - 5 (3.5) 4 (3.2) 8 (4.3)
Father’s Education
Less than High School 23 (53.5) 34 (50.0) 38 (54.3) 26 (18.2) 24 (19.4) 34 (18.4)
High School/GED 13 (30.2) 13 (30.2) 11 (15.7) 28 (19.6) 15 (12.1) 50 (27.0)
Some college 2 (4.7) 2 (4.7) 8 (11.4) 26 (18.2) 36 (29.0) 30 (16.2)
1.124 0.069
University or higher 3 (7.0) 16 (23.5) 9 (12.9) 40 (28.0) 26 (21.0) 43 (23.2)
Don’t know - - - 14 (9.8) 16 (12.9) 17 (9.2)
Missing 2 (4.7) 2 (2.9) 4 (5.7) 9 (6.3) 7 (5.7) 11 (6.0)
Sample sizes may not add up to marginal totals due to missing values. 1 Differences between proportions were
performed using chi-square tests of homogeneity by weight status for each of the study variables, separately by
country. Statistically significant results are in bold.
 not more likely to report more depressive symptoms than healthy-weig
youths in the US, who are more likely to report depressive symptoms than
(3.2 vs. 2.3, respectively). The presence of depressive symptoms is greater
overweight, and obese youth in Mexico (3.1, 3.7, 3.9, respectively) than thos
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scores scores than healthy-weight
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psychosocial, in Mexico
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(n = 181).
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youths (Tables 2 and larger
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results However,
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US are
5 considered
2.1 not more
± 0.8 2.6 ±0.8 2.7 ±0.7
r various psychosocial, behavioral,
Table 2. Table and2.tosocio-
Comparison
likely Comparison
report of that
likely various their
to report ofparents
various
psychosocial,
that their arepsychosocial,behavioral,
concerned
parents are about behavioral,
concerned and
their weight,
about and
socio-environmental socio-environmental
as compared
their
Socio-environmental weight, factorsas to healthy
compared factors weight byfactors
to healthy BMI weight by BMI
statistically significant. youthsyouths (Tables 2 and 3). All the Perceived parental concern which was considered
d BMI status. Within the domain category ofcategory
psychosocial
among among youths in youths
(Tables
Mexico in
2(n and =aforementioned
Mexico3).
181). All(n 181).results had
the=aforementioned a p-value
results
regarding weight
had ofa<0.05,
p-value of <0.05,1which to 5 was2.7 ±considered
1.2 3.2 ±1.1 3.6 ±1.0
statisticallystatistically
significant. significant.
e US are more likely to report being dissatisfied Healthy Healthy Overweight
Perceived
Overweight
parent
Obese
body size (PBIA)
Obesefactors
1 to 13 4.3 ± 1.2 4.9 ± 1.5 5.6 ±1.4
Table 2. Comparison of various Range psychosocial, * Rangebehavioral, * andMother socio-environmental
healthy values
P overweight
1ⱡ to 4 by BMI
Poverweight
P
2.8ⱡ ±ⱡ 0.7
obese P
2.6 ⱡ± 0.8
obeseƚ
Ptrend Ptrend2.6
ƚ ± 0.7
verweight or obese, and to have lower Table weight- 2. Comparison
Table 2. Comparisonof various Mean ±SDMean
psychosocial,
of various ±SD±SD
Mean
behavioral,
psychosocial, Mean
Father
and ±SD
healthy
Mean values
±SD
socio-environmental
behavioral, and Mean ± SD 1by
factors
socio-environmental to BMI
4 factors 2.1 by
± 0.6BMI 2.3 ± 0.8 2.3 ± 0.8
category among youths in Mexico (n = 181). Home availability of healthy foods 1 to 4 3.1 ± 0.7 3.0 ± 0.7 2.9 ± 0.7
category among youths in Mexico (n in
= 181).
wever, overweight or obese youths in Psychosocial
Psychosocial Factors
Mexico are Factors
category among youths Mexico (n = 181).
* A higher score indicates a greater frequency or agreement; Reference category for compariso
¶
DissatisfiedDissatisfied
with Body with Image Body Image 1 to Healthy 5 1 2.7
to 5± 1.3 2.7
Overweight
Healthy ± 1.3
3.1 ± 1.1
Healthy Obese
Overweight 3.1 ± 1.1
3.8
Obese
Overweight ± 0.9 3.8
Obese ± 0.9
0.034 0.034
<0.001 <0.001 <0.001
oms than healthy-weight youths,
DepressionDepression
unlike
symptoms symptoms
obese Range *
(CDI-S) (CDI-S)0 toMean 20 ± 0SD
Range *
to
3.120 ± 3.3
Range *
Mean ±3.1
SD ± 3.7
3.3
Mean
Mean± 3.2
±
Differences between
SD 3.7
±SD ± 3.9
Mean 3.2 Poverweight
±SD3.1
±SD 3.9±±SD 0.364
ⱡ
P means were performed
P
3.1 PPobese 0.364
overweight obese
ⱡ
overweight
ⱡ trend ƚ obese
0.223trend 0.223
ⱡ ƚ
PusingPPt-tests; Cuzick’s
P
0.100
trend ƚ
trend test; statistically sign
0.100
Mean ± SD Mean ±Mean
SD ± Mean
pressive symptoms than healthy-weight
Self-perceptionSelf-perception
regarding
Psychosocial Factors
youths
Psychosocial
regarding
weight Factors
Psychosocial
weight 1 to 5 Factors1 2.2 to 5± 0.8 2.2 ± 0.8
2.8 ± 0.7 2.8 ± 0.7
3.5 ± 0.6 3.5 ± 0.6
<0.001 <0.001
<0.001 <0.001 <0.001
Dissatisfied with Body Image
Dissatisfied with Body Image 1 to 5 2.71±to1.35 3.1±±1.3
2.7 1.1 3.8±
3.1 ±1.1
0.9 0.034
3.8 ±0.9 <0.001
0.034 <0.001 <0.001 <0.001
ve symptoms is greater Perceived
among
Dissatisfied Perceived
Body Shape
healthy-weight,
with Body Image Body
Depression(PBIA) Shape
symptoms 1 to (PBIA)
Depression 5(CDI-S)1 to 13
symptoms 2.7 ± 01
1.3
(CDI-S)toto 20 13
3.0 ± 1.5 3.1
3.1 3.0
±201.1
0±to3.3
± 4.4
1.53.1
±±1.3
3.7 3.23.8 ±
±3.3 4.40.9±3.9
3.7
1.3
6.3
±±3.2
±1.6 0.034
3.1 6.3± 3.1
0.364
3.9
±<0.001
1.6 0.223<0.001
0.364
<0.001
<0.001 <0.001<0.001
0.1000.223 0.100
<0.001
Depression
Body symptoms
Weight Body Weight
(CDI-S)
Description Description
Self-perception 0 to 20 weight
regarding
Self-perception 1 to 5 ± 3.3
3.1
regarding 1to3.1
1weightto
5 5± 0.9 3.7
2.2 1±to3.1
±
0.853.2± 3.9
0.92.2
±±0.6
2.8 0.73.9 ±
±0.8 3.93.1± 0.6
4.3
3.5
2.8 ±±0.7±0.6 0.364
0.6 4.3±0.6
<0.001
3.5 ±<0.001
0.6 <0.001 0.223<0.001
<0.001 <0.001
<0.001 0.100 <0.001
<0.001 <0.001 <0.001
respectively) than those in theFatUS
Self-perception
Feeling regarding
Feeling
(2.1,
weight
Fat
2.8, 3.2,
Perceived Body1 to 5 (PBIA)
Shape
Perceived to 2.2
1Body ± 0.8
5Shape 1(PBIA)
to 13
1 2.4
to 5± 1.2 2.8
3.0 ±130.7
1±to1.5
2.4 4.4
1.23.0
± 3.1 ±±1.11.33.5 ±
±1.5 3.10.6 6.3
4.4
± ±±1.3
1.1
3.7 ±1.0<0.001
1.6 <0.001
6.3
3.7±1.6 <0.001
1.0 <0.001
±0.006 <0.001 0.006 <0.001 <0.001<0.001
<0.001
<0.001 <0.001 <0.001
y overweight or obesePerceived
youths Body
in Shape
Mexico (PBIA)Body Weight Description
is lower 1Body
to 13Weight Description3.0 ± 1.5 1 to 5 3.1 1±to
4.4 0.9
±51.3 3.1 3.9±±0.9
0.66.3 ± 1.6 4.3±
3.9 ±0.6
0.6 <0.001
<0.001
4.3 ±0.6 <0.001
<0.001
<0.001 <0.001 <0.001 <0.001
<0.001
Youth Youth
weight-related weight-related
quality qualityFat
of life of life
Body Weight Description Feeling Fat 1Feeling to 5 0 to 100 3.1 ± 0.9 10to 5
to 100
75.8 2.4 1
3.9± 1.2
to± 50.6
± 28.1 75.8 ±65.1 3.1
2.4 ±± 1.1
1.2 4.3
28.1±26.0 65.1 ± ± 0.63.7
3.1 ±± 1.0
1.1 <0.001
0.006
3.7
26.0±26.4 52.9 ±0.045
52.9 ± 1.0 26.4 <0.001
<0.001
0.006 <0.001
0.045 <0.001
<0.001
<0.001 <0.001
<0.001 <0.001
respectively). (YQOL-W)
Feeling Fat (YQOL-W) Youth weight-relatedYouth quality
1 toweight-related
5 of life
2.4quality
± 01.2 of life
to 100 3.1
75.8 ±
± 28.1
0 to 1001.1 75.865.1±±28.1 3.7 ± 1.0
26.0 52.9±
65.1 ±26.0
26.4 0.006
0.045
52.9 ±26.4 <0.001
<0.001
0.045 <0.001 <0.001 <0.001
<0.001
(YQOL-W) (YQOL-W)
Behavioral
Youth weight-related qualityBehavioral
Factors
of life Factors
he US have lower healthy lifestyle priorities (3.0
Behavioral0 toFactors
100 Behavioral 75.8 ± 28.1
Factors 65.1 ± 26.0 52.9 ± 26.4 0.045 <0.001 <0.001
(YQOL-W) Healthy lifestyle priorities
Healthy lifestyle priorities
Healthy lifestyle priorities
Healthy 1 topriorities
lifestyle 4 11 to
4 4± 0.6
to2.8 2.81±to 2.8
0.64
± 2.9
0.62.8 0.7 2.9 2.9
± ±0.7
2.9 ±0.6 ±2.82.8
0.7
±±0.7± 0.7 2.8
0.7 2.8± 0.7
0.797 ± 0.797
0.7 0.723 0.797
0.797
0.723
0.5690.723
0.723
0.569
0.569
0.569
vs. 1.8, respectively), Physically
andBehavioral
are active
less
Physically likely
Factors Physically to
active active eat
Physically active 0 to 3 00 to
3 3± 1.0
to1.5 1.50±to 1.5
1.03 ± 1.61.01.5 1.0 1.6 1.6
± ±1.0
1.6 ±1.0 ±1.31.3
1.0
±±1.0± 1.0 1.3
1.0 1.3± 1.0
0.785 ± 0.785
1.0 0.255 0.785 0.785 0.255
0.1760.255 0.255
0.176
0.176 0.176
Healthy
Fast lifestyle priorities
Fast foodand
food consumption Fast food consumption
consumption Fast1 food
to 4 consumption
1 to 2.8 5 ± 0.6 11 to1.1
5 5± 0.4
to 1.1 1±to
2.9 0.4
± 50.7± 1.1
1.1 1.1
0.41.1 ±0.4
0.52.8 ±
± ±0.5 1.10.7±1.01.0
1.1 ±±0.5
0.5 0.4
± 0.4 0.797 0.765
1.0
1.0± 0.4 0.4 0.073
± 0.765 0.723 0.765
0.765 0.023
0.073 0.569 0.073
0.073 0.023
0.023 0.023
ght youth in the US. Overweight
Physically activeEats breakfast Eats
obese
breakfast Eats breakfast
0 to 3 1
1.5 ± 1.01 to 2to 2 1.7 1± 0.4
to
1.6 ± 21.0± 0.4 1.6
1.7 ±± 0.4
0.4 1.3 ± 1.6
1.6 ±± 0.4
0.4 0.416
1.6 ± 0.4 0.205
0.416 0.2390.205 0.239
Eats breakfast 1 to 2 1.7 ± 0.4 1.7 1.61.2± ±0.4 1.61.0±1.41.6
0.4 ± 0.4 0.785 1.6±0.2± 0.416
0.4 <0.001 0.255 0.416 0.176 0.205
0.205 0.239 0.239
ore likely to engage Fast
in weight control
food consumption
Weight control
behaviors,
Weight control
behaviors
behaviors
Weight
1 to 5 control behaviors
1.1 ± 0.4 1
11
to 2
to
2 2± 0.2
1.2 1± 0.2
to 2
1.1 ± 0.5
1.2 ± 0.21.8
1.4 ± 0.2
0.2 1.0 ± 0.4
0.4 1.4 1.8
1.4
±
±±
1.80.2
0.2
0.2 0.002
1.4
0.765
1.4±0.4±0.002
0.2 0.003
0.002
0.073 0.001
<0.001
0.023 0.001
0.005 0.002 <0.001 0.001
EatsWeight
breakfastcontrol behaviors to 2 1 to 1.7 2 ± 0.4 to1.2
1.6 ±20.4 1.41.5 ±±0.2 1.6 ± 0.4 1.4 ±0.2 0.416 0.205 <0.001 0.239 0.001
Exercises 1.51±to0.5 ±0.5 ±0.4
0.4 0.005 0.0060.003
1Exercises ± 1.8 0.006
to healthy-weight youth. Thebehaviors
Weight Exercises
control only statistically
Exercises Eat less, few calories,
1
Eat less,
to 2
low-fat
few foods
1 calories,
to 1.22 ±low-fat11
0.2
to1.5
2foods
to 1.31±to
2± 0.5 1.4
0.52 ± 1.8
1.5
± 0.2
1.5
0.51.3 ±0.5
±±0.40.5 1.8 1.5
1.4 ± ±
0.2
1.6 ±±0.5
0.4
1.8 0.5
±0.4 0.002 0.045
1.6
1.8±0.5 0.4 0.032
±0.005 0.045 0.005
<0.001
0.046
0.0030.032
0.001
0.046
0.003
0.006 0.006
Fasting Fasting 1 to 2 1.11±to0.32 1.1±±0.3
1.1 0.3 1.2±±0.3
1.1 0.4 0.415
1.2 ± 0.4 0.174
0.415 0.1680.174 0.168
obese youths in both Eat less, fewEat
countries
Exercises less, few
calories,
include Diet calories,
low-fat
being
pills, foods low-fat
1Diet
powders, to pills, 1foods
2or liquids to 1.5
powders, 2 ± 11
0.5
or liquids
to
2 2± 0.5
to1.3 1.8
1.0 1±to
1.3
±
0.02
0.4± 1.5
0.51.0
±±0.5
1.0 0.11.8 ±
±0.0 1.50.4±1.1
1.0
0.5
1.6
±±0.1±0.5 0.005
0.2 1.6± 0.2
0.429
1.1
±0.045
0.5 0.112 0.003 0.045
0.429 0.032
0.058 0.006 0.032
0.112 0.046
0.058
0.046
Eat less, few calories,
Fasting low-fat
Fasting foods
Restrained 1 to 2 eating
eatingRestrained
behaviors 1 to
(DEBQ-R) 2 ± 0.5
1.3
behaviors 11 to
5 2± 0.3
to1.1
(DEBQ-R) 1.5
2.1 1±to±
0.850.5
1.1 ± 1.1
0.32.1 0.81.6 ±
± ±0.3
2.6 ±0.8 1.10.5±2.71.2
2.6 0.3
±±0.8± 0.4 0.045
0.7 1.2±0.7
0.001
2.7 ± 0.415
0.4 <0.001 0.032 0.415
0.001 0.174
<0.001 0.046 <0.001
<0.001 0.174
0.168 0.168
about their weight and that
Fasting theirDietparents
Diet pills, powders,
have
liquids 1or
pills,Socio-environmental
orpowders,
a Socio-environmental
to 2 factors 1.1 ± 0.3
liquids 1 to 2 factors to 2± 0.01.1 ±
1 1.0 0.0 ± 0.11.2 ±
1.00.3± 1.0 1.00.4± 1.1
0.1 ± 0.2 0.415 0.2 0.174 0.429
1.1 ± 0.429 0.1120.168 0.112 0.058 0.058
Diet pills, powders, or liquids Perceived parental 1concern
to 2 parental1.0 ± 0.0 1.0 ± 0.1 1.1 ± 0.2 0.429 0.112 0.058
ver, overweight youths in the
Restrained US
eating
Restrained eating behaviors
are
Restrained
behaviorsnot
eating more
(DEBQ-R)
regarding weight
Perceived
behaviors (DEBQ-R)
regarding weight
1 to 5
concern
11 to
5 5± 0.8
to2.1 2.71±to 2.1
1.25 ± 2.60.8 ±
3.2
2.7 1.1 2.6 3.2
±0.8
±1.2 ± 0.8
2.7
3.6 ±±1.1±
1.0 0.7 2.7
0.0316
3.6 ±
±1.0 0.7
0.001 0.0316 0.001
<0.001 <0.001
<0.001
<0.001
<0.001
<0.001
<0.001
1 to 5size (PBIA)2.1 ± 0.8 2.6 ± 0.8 2.7 ± 0.75.6 ±1.4 0.001 <0.001 <0.001 <0.001
ut their weight, as compared
(DEBQ-R) to healthy weight
Socio-environmental
Socio-environmental Perceivedfactors
parent bodyfactors
Perceived parent body size 1 to 13
(PBIA) 4.31±to1.2
13 4.9±±1.2
4.3 1.5 4.9 ±1.5 0.0292
5.6 ±1.4 <0.001
0.0292 <0.001 <0.001
Perceived Mother healthy
parental concern values
Mother healthy values 1 to 4 2.8 1± 0.7
to 4 2.6
2.8 ±± 0.8
0.7 2.6
2.6 ±± 0.7
0.8 0.1260
2.6 ± 0.7 0.1383
0.1260 0.178
0.1383 0.178
Perceived parental concern
lts had a p-value of <0.05, which was considered
Socio-environmental factors
Father healthy Father
values healthy 1 values
to 5 11 to
4 5± 1.2
to2.7 2.11±to 2.7
0.64 ± 3.21.22.1
±±1.1
2.3 0.8 3.2 2.3
±0.6 ± 1.1
3.6
2.3 ±±0.8±1.0 2.3
0.8 3.6± 0.8
0.1656 ±0.0316
1.0 0.13330.16560.0316 <0.001
0.191
0.1333 <0.001
0.191
regarding
Perceived regarding
weight
parental weight
concernHome availability <0.001 <0.001
1oftohealthy
Home foodsof
availability
5 1 tofoods
2.7healthy
± 1.2 4 3.1
3.21±to
0.7
±41.1 3.1 3.0±±0.7
0.73.6 ± 1.0 2.9±±0.7
3.0 0.7 0.5642
2.9
0.0316 ± 0.7 0.1474
0.5642 0.103
<0.001 <0.001 0.103
0.1474
regarding weight Perceived parent body size (PBIA) 1 to
Perceived parent body size (PBIA)
* A higher score*A 1 to
indicates
higher 13 indicates
a greater
score a 13
4.3
frequency ±or1.2
greater 4.3 ±¶4.9
agreement;
frequency 1.2
Reference
or agreement; 4.9
±1.5 category ±for
1.5comparisons
5.6
¶ Reference 1.4 5.6
±category ±0.0292
1.4 BMI groups;
between
for comparisons 0.0292
<0.001
between ⱡ
BMI groups; <0.001
ⱡ <0.001
Perceived parent bodyvalues
Mother size (PBIA)values1 to 13 1 to 4.3
healthy 4 ±performed
1.21 2.8
towere
4±using4.9 ± 2.81.5 5.6 ±
2.61.4 0.0292 <0.001 <0.0010.1383
Mother healthy Differences between meansbetween
were 0.7 t-tests; ƚ± 0.7 ±t-tests;
2.6
Cuzick’s 0.8 ± 2.6
trendƚ Cuzick’s
test; 0.8 ± 0.7
statistically 2.6 ±0.1260
significant 0.7significant
results 0.1260
0.1383
are in bold. 0.178 0.178
Mother healthy values Differences
1 to 4 means
2.8 ± 0.7 performed
2.6 ± 0.8 using 2.6 ± 0.7 trend test; statistically
0.1260 0.1383 results are in
0.178bold.
vioral, and Father
Father healthy
socio-environmental
Father healthy factors
healthy values 1 to 4 1 to 2.1
values
values by BMI
4 ± 0.61 2.1to 4± 0.62.3 ± 2.10.8± 2.3
0.6 ± 0.82.3 ± 2.30.8± 2.3
0.8 ± 0.8 0.16562.3 ±0.1656
0.8 0.13330.1656 0.13330.191 0.13330.191 0.191
HomeHome Home
availability
availability availability
of healthy
of healthy of healthy
foods foods 1 to 4 foods 4 ± 0.71 3.1
1 to 3.1 to 4± 0.73.0 ± 3.10.7± 3.0
0.7 ± 0.72.9 ± 3.00.7± 2.9
0.7 ± 0.7 0.56422.9 ±0.5642
0.7 0.14740.5642 0.14740.103 0.14740.103 0.103
* Aindicates
higher score ⱡ ⱡ
* A higher
* A higher score
score indicates a indicates
greater
a greater a greateroror
frequency
frequency frequency or agreement;
agreement;
agreement; Reference Reference
Referencecategory category
for
category for comparisons
comparisons
for between
¶
comparisons between
BMI
between BMI groups;
¶
groups;
BMI
Overweight Obese ⱡ
Differences Differences
ⱡ between means were performed using t-tests;trend
Cuzick’s trend ƚ
test; statisticallyƚsignificant results
bold.are in bold.
Poverweight
groups; Pbetween
Differences
obese means
Ptrend
between ƚ were
meansperformed
were using t-tests;
performed usingCuzick’s
t-tests; test; statistically
Cuzick’s trend test;significant results
statistically are in
significant
Mean ±SD Mean ±SD
results are in bold.
3.1 ±1.1 3.8 ±0.9 0.034 <0.001 <0.001
3.7 ± 3.2 3.9 ± 3.1 0.364 0.223 0.100
2.8 ±0.7 3.5 ±0.6 <0.001 <0.001 <0.001
4.4 ±1.3 6.3 ±1.6 <0.001 <0.001 <0.001
3.9 ±0.6 4.3 ±0.6 <0.001 <0.001 <0.001
3.1 ±1.1 3.7 ±1.0 0.006 <0.001 <0.001

65.1 ±26.0 52.9 ±26.4 0.045 <0.001 <0.001

2.9 ± 0.7 2.8 ± 0.7 0.797 0.723 0.569

 breakfast (1.5, 1.6, respectively)
breakfast than healthy-weight
(1.5, 1.6, respectively) youth
Fast foodin
than healthy-weight the US. inOverweight
youth
consumption 1 and
to 5 obese
the US. Overweight 1.1 ±and
0.4 obese
1.1 ± 0.5 1.0 ± 0.4
likely tolikely
reportto report
that their
participants that their
inparents
both parents
inare
countries
participants bothare are
concerned
also concerned
about
significantly
countries are also more about
their
likely
significantly totheir
Eatsweight,
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moreengage
likelyweight,
as engageas
compared
intoweight in compared
1 to
control to 1.7 ±to
2 healthy
behaviors,
weight control healthy
0.4 weight
behaviors,1.6 ± 0.4weight
1.6 ± 0.4
Weight control behaviors 1 to 2 1.2 ± 0.2 1.4 ±0.2 1.4 ±0.2
youths 2such
youths (Tables (Tables
and as 3).2such
andas
All
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the
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as compared
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<0.05, <0.05,
which
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considered
1statistically
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1.5 considered
±statistically ±0.4 1.8 ±0.4
significant socio-environmental factors reported
factorsbyreported
obese Eat
youths fewin both countries
bothinclude
1 to 2 being
7 ofsignificant socio-environmental by
less,obese youths
calories, infoods
low-fat countries include
1.3 ± 0.5 being 1.5 ±0.5 1.6 ±0.5
statistically
statistically significant.significant.
15 Fasting 1 to 2 1.1 ± 0.3 1.1 ± 0.3 1.2 ± 0.4
more likelymore to think likely thattotheir thinkparents
that their are parents
concerned are about
concerned their about
weighttheir andweight
that their andparents
that their have a
parents have a
Diet pills, powders, or liquids 1 to 2 1.0 ± 0.0 1.0 ± 0.1 1.1 ± 0.2
larger bodylarger size than bodyhealthy-weight
size than healthy-weight youth. However, youth. overweight
However,
Restrained eating youths
behaviorsin
overweight the US are
youths
(DEBQ-R) in not
1 tothe
5 US more are
2.1 not more
± 0.8 2.6 ±0.8 2.7 ±0.7
r various psychosocial, behavioral,
Int. J. Environ. Res. Public
Table
Table 2. Comparison andHealth
2. socio-
Comparison
likely to report2019,
likely 16,
of that
various 1534
to report of various
psychosocial,
their parents that their psychosocial,
are parents
concerned behavioral,
are about behavioral,
concerned and
their about and
socio-environmental
weight, socio-environmental
as compared
their
Socio-environmental weight, as to
factors healthy
compared factors weight by BMI
to healthy 8
factors of 15
weight by BMI
youthsyouths(Tables 2 and 3). All the Perceived parental concern which was considered
d BMI status. Within the domain category ofcategory
psychosocial
among among youths in youths
(Tables
Mexico in
2(n and=aforementioned
Mexico
3).
181). All(n 181).results had
the=aforementioned a p-value
results
regarding weight
had ofa<0.05,
p-value of <0.05,1which to 5 was2.7 ±considered
1.2 3.2 ±1.1 3.6 ±1.0
statisticallystatistically
significant. significant.
e US are more likely to report being dissatisfied Healthy Healthy Overweight
Perceived parent body size (PBIA)
Overweight Obese Obesefactors
1 to 13 4.3 ± 1.2 4.9 ±1.5 5.6 ±1.4
Table 3. Comparison of various Range psychosocial, * Rangebehavioral, * andMother socio-environmental
healthy values 1 to 4 by BMI
Poverweight 1ⱡ toP4overweight
2.8ⱡ ±ⱡ 0.7
Pobese
2.6 ⱡ± 0.8
obeseƚ
PPtrend Ptrend2.6
ƚ ± 0.7
verweight or obese, and to have lower Table weight- 2. Comparison
Table 2. Comparison of various Mean ±SDMean
psychosocial,
of various ±SD±SD
Mean
behavioral,
psychosocial, Mean
Father
and healthy
Mean±SD values
±SD
socio-environmental
behavioral, and Mean ± SD by BMI
factors
socio-environmental 2.1
factors by BMI± 0.6 2.3 ± 0.8 2.3 ± 0.8
category among youths in the Unites States (n = 452). Home availability of healthy foods 1 to 4 3.1 ± 0.7 3.0 ± 0.7 2.9 ± 0.7
category among youths in Mexico (n in
= 181).
wever, overweight or obese youths in Psychosocial
Psychosocial Factors
Mexico are Factors
category among youths Mexico (n = 181).
* A higher score indicates a greater frequency or agreement; ¶ Reference category for compariso
DissatisfiedDissatisfied
with Body with Image Body Image 1 to Healthy 5 1 2.7
to 5± 1.3 2.7 ± 3.1
Overweight
Healthy 1.3 ±1.1 Obese
Overweight
Healthy 3.1 ±Obese
1.1 ±0.9 Obese
3.8
Overweight 3.8 ±0.034
0.9 0.034
<0.001 <0.001 <0.001
oms than healthy-weight youths,
DepressionDepression
unlike
symptoms symptoms
obese Range *
(CDI-S) (CDI-S)0 toMean 20 ± 0SD
Range *
to
3.120 ± 3.3
Mean
Range *
±3.1
SD ± 3.7
3.3 ± 3.2
Mean
Mean ±
Differences between
SD 3.7
±SD ± 3.9
Mean 3.2 ±SD3.1
±SD
means ⱡwere performed
Poverweight
Poverweight
3.9±±SD 0.364
Pobese ⱡ
3.1 PPoverweight
ⱡ P
obese 0.364
using
trend P
0.223 Pobese
ⱡ
ƚ t-tests; ƚ Cuzick’s
trend 0.223
Ptrend ƚ trend test; statistically sign
0.100 0.100
Mean ± SD Mean ±Mean
SD ± Mean
pressive symptoms than healthy-weight
Self-perception
Self-perception regarding
Psychosocial Factors
youths
Psychosocial
regarding
weight Factors
Psychosocial
weight 1 to 5 Factors1 2.2to 5± 0.8 2.2 ± 0.8
2.8 ± 0.7 2.8 ± 0.7
3.5 ± 0.6 3.5 ± 0.6
<0.001 <0.001
<0.001 <0.001 <0.001
Dissatisfied with Body Image
Dissatisfied with Body Image 1 to 5 2.71±to1.35 3.1±±1.3
2.7 1.1 3.8±
3.1 ±1.1
0.9 0.034
3.8 ±0.9 <0.001
0.034 <0.001 <0.001 <0.001
ve symptoms is greater Perceived
among
Dissatisfied Perceived
Body Shape
healthy-weight,
with Body Image Body
Depression(PBIA) Shape
symptoms1 to (PBIA)
Depression 5(CDI-S)1 to 13
symptoms 2.3 ± 01
0.9toto
(CDI-S) 20 13
3.0 ± 1.5 2.8
3.1 3.0
±201.0
0±to3.3
± 4.4
1.53.1
±±1.3
3.7 4.40.9
3.23.2 ±
±3.3 ±3.9
3.7
1.3
6.3
±±3.2
±1.6<0.001
3.1 6.3± 3.1
0.364
3.9
±<0.001
1.6 0.223
<0.001
0.364
<0.001
<0.001
0.1000.223<0.001<0.001 0.100
<0.001
Depression
Body symptoms
Weight Body Weight
(CDI-S)
Description Description
Self-perception 0 to 20 weight
regarding
Self-perception 1 to 5 ± 2.6
2.1
regarding 1to3.1
1weightto
5 5± 0.9 2.8
2.2 1±to3.1
±
0.853.5± 3.9
0.92.2
±±0.6
2.8 ±0.8 3.93.6
0.73.2 ± ± 0.6
4.3
3.5
2.8 ±±0.7±0.6 0.059
0.6 4.3±0.6
<0.001
3.5 ±<0.001
0.6 <0.0010.001<0.001
<0.001 <0.001
<0.001 0.003 <0.001
<0.001 <0.001 <0.001
respectively) than those in theFatUS
Self-perception
Feeling regarding
(2.1,
Feeling weight
Fat
2.8, 3.2,
Perceived Body1 to 5 (PBIA)
Shape
Perceived to 1.9
1Body ± 0.5
5Shape 1(PBIA)
to 13
1 2.4
to 5± 1.2 2.6
3.0 ±130.7
1±to1.5
2.4 4.4
1.23.0
± 3.1 ±±1.11.33.1 ±
±1.5 3.10.7 6.3
4.4
± ±±1.3
1.1
3.7 ±1.0<0.001
1.6 <0.001
6.3
3.7±1.6 <0.001
1.0 <0.001
±0.006 <0.001 0.006<0.001
<0.001 <0.001<0.001
<0.001 <0.001 <0.001
y overweight or obesePerceived
youths Body
in Shape
Mexico Body Weight Description
(PBIA) is lower 1Body
to 13Weight Description 1 to 5
2.4 ± 1.3 3.1
3.91±to
0.9
±51.4 3.1 3.9±±0.9
0.65.2 ± 1.6 4.3±
3.9 ±0.6
0.6 <0.001
<0.001
4.3 ±0.6 <0.001
<0.001
<0.001 <0.001 <0.001 <0.001
<0.001
Youth Youth
weight-related weight-related
quality of quality
life of life
Body Weight Description Feeling Fat 1Feeling to 5 Fat 0 to 100 10to
2.8 ± 0.7 to5 100
75.8 2.4
± 28.13.51±75.8
1.2
to±50.7± 3.1
2.4
28.1
65.1 ±1.2
1.14.165.1
±±26.0 ± 0.8 3.7
3.1
± ±±1.1
26.0
52.9 1.0
±26.4 <0.001
0.006
3.7
52.9 ±1.0
±0.045 <0.001
26.4<0.0010.006 0.045<0.001
<0.001 <0.001<0.001
<0.001 <0.001 <0.001
respectively). Feeling Fat (YQOL-W)
(YQOL-W) Youth weight-related
Youth quality
1 toweight-related
5 of life
2.0quality
± 01.1 of life
to 100 2.8
75.8 ±
± 28.1
0 to 1001.3 75.8
65.1±±28.1 3.3 ± 1.2
26.0 52.9±
65.1 26.4 <0.001
±26.0 0.045
52.9 ±26.4 <0.001
<0.001
0.045 <0.001 <0.001 <0.001
<0.001
(YQOL-W) (YQOL-W)
Behavioral
Youth weight-related Behavioral
Factors
quality of life Factors
he US have lower healthy lifestyle priorities (3.0
Behavioral0 toFactors
100 Behavioral 90.4 ± 14.1
Factors 78.1 ± 23.0 67.0 ± 27.5 <0.001 <0.001 <0.001
(YQOL-W) Healthy lifestyle priorities
Healthy lifestyle priorities
Healthy lifestyle priorities
Healthy 1 topriorities
lifestyle 4 11 to
4 4± 0.6
to2.8 2.81±to 2.8
0.64
± 2.9
0.62.8 0.7 2.9 2.9
± ±0.7
2.9 ±0.6 ±2.82.8
0.7
±±0.7± 0.7 2.8
0.7 2.8± 0.7
0.797 ± 0.797
0.7 0.723 0.797
0.797
0.723
0.569 0.723
0.723
0.569
0.569
0.569
vs. 1.8, respectively), Physically
andBehavioral
are active
less
Physicallylikely
Factors active
Physically toactive
eat
Physically active 0 to 3 00 to
3 3± 1.0
to1.5 1.50±to 1.5
1.03 ± 1.6
1.01.5 1.0 1.6 1.6
± ±1.0
1.6 ±1.0 ±1.31.3
1.0
±±1.0± 1.0 1.3
1.0 1.3± 1.0
0.785 ± 0.785
1.0 0.255 0.785 0.785 0.255
0.176 0.255 0.255
0.176
0.176 0.176
Healthy
Fast lifestyle priorities
Fast foodand
food consumption Fast food consumption
consumption Fast1 food
to 4 consumption
1 to 53.1± 0.7 11 to1.1
5 5± 0.4
to 1.13.0±
1±to
0.450.6± 1.1
1.1 1.1
0.41.1 ±0.4
0.53.0 ±
± ±0.5 1.10.7 ±1.01.0
1.1 ±±0.5
0.5 0.4
± 0.4 0.099 0.765
1.0
1.0± 0.4 0.4 0.073
± 0.765 0.042 0.765
0.765 0.023
0.073 0.028 0.073
0.073 0.023
0.023 0.023
ght youth in the US. Overweight
Physically activeEats breakfast
obese
Eats breakfast Eats 0 breakfast
to 3 1 to 2
1.8 ± 1.1 1.7 1±to
1.6 0.4
± 21.0 1.6±±0.4
1.7 0.41.6 ± 1.0 1.6±±0.4
1.6 0.4 0.416
1.6 ± 0.4 0.205
0.416 0.2390.205 0.239
Eats breakfast 1 to 2 1to1.7
to 2± 0.4 1.7 ± 1.6
0.41.2
± ±0.4 1.6 1.4±1.41.6
0.4 ± 0.4 0.105 1.6±0.2
± 0.416
0.4 <0.0010.038 0.416
0.205 0.058 0.205
0.239 0.239
ore likely to engage Fast
in Weight
weight control
food consumption
Weight
behaviors,
Weight
control
control
behaviors
behaviors
Weight
1 to 5 control behaviors 1
1.8 ± 0.9
11
2
to
2 2± 0.2
1.2 1± 0.2
to 2
1.8 ± 1.0
1.2
1.4 ± 0.2
0.2 1.6 ± 0.7 ±± 0.2
0.2 0.002
1.4
0.639 0.002
0.011 0.001 <0.001
0.041 0.001
control behaviors Exercises Exercises 1 to 2 to1.2 1.51±to0.52 ± 1.4
0.2 ±
1.8
1.5 0.4 1.4 1.8
±0.2
±0.5 ±1.80.2
1.4
±±0.4±
0.4 0.2 1.4
0.005
1.8 ±
±0.4 0.2
0.002 0.005 0.002
0.003 <0.001
0.0060.003 <0.001
0.001
0.006 0.001
Eats breakfast 1 to 2 1.6 ± 0.4 1.6 ± 0.4 1.5 ± 0.4 0.395 0.010 0.008
to healthy-weight youth. Thebehaviors
Weight Exercises
control only statistically
Exercises Eat less, few calories,
Eat less,
1 to 2
low-fat
few foods
1 calories,
to 1.3 11
2 ±low-fat
0.2
to1.5
2foods
to 2± 0.51.31±to
1.3
0.52 ± 1.8
1.5
± 0.2
1.5
0.51.3 ±0.5
±±0.40.5 1.8 1.5
1.4 ± 0.2±1.6 ±±0.5
0.4
1.8 0.5
±0.4 0.021 0.045
1.6
1.8±0.5 0.4 0.032
±0.005 0.045 0.005
0.001
0.046
0.003 0.032
<0.001
0.046
0.003
0.006 0.006
Fasting Fasting 1 to 2 1.11±to0.32 1.1±±0.3
1.1 0.3 1.2±±0.3
1.1 0.4 0.415
1.2 ± 0.4 0.174
0.415 0.1680.174 0.168
obese youths in both Eat less, fewEat
countries
Exercises less, few
calories,
include calories,
low-fat
being foods
Diet pills, powders,1low-fat
to 2 1foods
or liquids
Diet pills, to 2
1.6 ± 0.5 1
1 to 2
powders, or liquids
to
1.3 2± 0.5 1.7
1.01±to 1.3
±
0.020.4± 0.5
1.5 ± 0.5
1.0±±0.0
1.0 0.11.7 1.5
± 0.4± 0.5
1.6
1.1±±0.1
1.0 ±
0.2 0.5 1.6
0.053
0.429
1.1
±
± 0.2
0.5
0.045 0.018
0.112
0.429
0.045
0.032
0.0580.112 0.020 0.032
0.046
0.058
0.046
Eat less, few calories,
Fasting low-fat
Fasting foods
Restrained 1 to 2 eating
eatingRestrained
behaviors 1 to
(DEBQ-R) 2 ± 0.5
1.4
behaviors 11 to
5 2± 0.3
to1.1
(DEBQ-R) 1.5
2.1 1±to±
0.850.5
1.1 ± 1.1
0.32.1 0.81.6 ±
± ±0.3
2.6 ±0.8 1.10.5 ±2.71.2
2.6 0.3
±±0.8± 0.4 0.003
0.7 1.2±0.7
0.001
2.7 ± 0.415 <0.001
0.4 <0.0010.001 0.415 0.174
<0.001 0.001 <0.001
<0.001 0.174
0.168 0.168
about their weight and that
Fasting theirDietparents
Diet pills, powders,
have
liquids 1or
a Socio-environmental
pills,Socio-environmental
orpowders, to 2 factors 1.1 ± 0.3
liquids 1 to 2 factors to 2± 0.01.1 ±
1 1.0 0.0 ± 0.11.1 ±
1.00.3± 1.0 1.00.3± 1.10.1 ± 0.2 0.577 0.2 0.281 0.429
1.1 ± 0.429 0.1120.224 0.112 0.058 0.058
Diet pills, powders, or liquids
Perceived parental 1concern
to 2 parental1.0 ± 0.2 1.0 ± 0.2 1.1 ± 0.2 0.726 0.691 0.648
ver, overweight youths in the
Restrained
Restrained
US
eating
eating
are
Restrained not(DEBQ-R)
eating
behaviors
behaviors regarding
more
weight
Perceived
behaviors (DEBQ-R)
regarding weight
1 to 5
concern
11 to
5 5± 0.8
to2.1 2.71±to 2.1
1.25 ± 2.6
0.82.7
±±0.8
3.2 1.1 2.6 3.2
±1.2 ± 0.8
2.7
3.6 ±±1.1±0.7 3.6
1.0 2.7±1.0
0.0316 ±0.001
0.7 <0.001
0.0316 0.001<0.001
<0.001
<0.001 <0.001
<0.001
<0.001
1 to 5size (PBIA)2.1 ± 0.8 2.5 ± 0.9 2.7 ± 0.85.6 ±1.4 0.001 <0.001 <0.001 <0.001
ut their weight, as compared
(DEBQ-R) to healthy weight
Socio-environmental
Socio-environmental Perceivedfactors
parent bodyfactors
Perceived parent body size 1 to 13
(PBIA) 4.31±to1.2
13 4.9±±1.2
4.3 1.5 4.9 ±1.5 0.0292
5.6 ±1.4 <0.001
0.0292 <0.001 <0.001
Perceived Mother healthy
parental concern values
Mother healthy values 1 to 4 2.8 1± 0.7
to 4 2.6
2.8 ±± 0.8
0.7 2.6
2.6 ±± 0.7
0.8 0.1260
2.6 ± 0.7 0.1383
0.1260 0.178 0.1383 0.178
Perceived parental concern
lts had a p-value of <0.05, which was considered
Socio-environmental factorsFather healthy Father
values healthy 1 values
to 5 11 to
4 5± 1.2
to2.7 2.11±to 2.7
0.64 ± 3.2
1.22.1
±±1.1
2.3 0.8 3.2 2.3
±0.6 ± 1.1
3.6
2.3 ±±0.8±1.0 2.3
0.8 3.6± 0.8
0.1656 ±0.0316
1.0 0.1333
0.16560.0316<0.001
0.191 0.1333 <0.001
0.191
regarding
Perceived regarding
weight
parental concernHome weightavailability <0.001 <0.001
Home1oftohealthy
availability
5 foodsof 1 tofoods
2.6healthy
± 1.3 4 3.1 1±to
2.7 0.7
±41.2 3.1 3.0±±0.7
0.73.2 ± 1.2 2.9±±0.7
3.0 0.7 0.5642
2.9
0.766 ± 0.7 0.1474
0.5642 0.103
<0.001 <0.001 0.103
0.1474
regarding weightPerceived parent body size (PBIA) 1 to
Perceived parent body size (PBIA)
* A higher score *Aindicates
higher1 to 13 indicates
a greater
score 4.3
frequency a 13±or1.2
greater 4.3 ±¶4.9
agreement;
frequency 1.2
Reference
or agreement; 4.9
±1.5 category ±for1.5comparisons
5.6
¶ Reference 1.4 5.6
±category ±0.0292
1.4 BMI groups;
between
for comparisons 0.0292
between <0.001
ⱡ
BMI groups; <0.001
ⱡ <0.001
Perceived parent bodyvalues
Mother size (PBIA)values1 to 13 1 to 3.9
healthy 4 ±performed
1.51 2.8towere4±using4.9 ± 2.81.6 5.1 ±
2.61.5 <0.001 <0.001 <0.0010.1383
Mother healthy Differences between meansbetween
were 0.7 t-tests; ƚ± 0.7 ±t-tests;
2.6
Cuzick’s 0.8
trendƚ Cuzick’s
test; ± 2.6
0.8 ± 0.7
statistically 2.6 ±0.1260
significant 0.7significant
results 0.1260
are in bold. 0.1383 0.178 0.178
Mother healthy values Differences
1 to 4 means
3.1 ± 0.9 performed
3.1 ± 0.8 using 3.1 ± 0.8 trend test; statistically
0.854 0.694 results are in
0.992 bold.
Father
vioral, and socio-environmental Father
healthy
Father healthy factors
healthy
values
values by BMI
values 1 to 4
1 to 4
2.8 ± 0.9
1 to
2.1 4± 0.6 2.1
2.6 ± 1.0
± 0.6
2.3 ± 0.8 2.3
2.9 ± 1.0
± 0.8
2.3 ± 0.8 2.3
0.154
± 0.8
0.1656 0.255
0.1656
0.1333 0.173
0.1333
0.191 0.191
Home Home Home
availability
availability availability
of healthy
of healthy foods foods of healthy
1 to 4 foods 1 to 3.2 4 ± 0.71 3.1 to 4± 0.73.2 ± 3.10.7± 3.0
0.7 ± 0.73.2 ± 3.00.8± 2.90.7 ± 0.7 0.888 2.9 ±0.5642
0.7 0.5330.5642 0.14740.391 0.1474 0.103 0.103
* Aindicates
higher score ⱡ ⱡ
* A higher
* A higher score
score indicates a indicates
greater
a greater a greateroror
frequency
frequency frequency or agreement;
agreement;
agreement; Reference Reference
Referencecategory category
for
category for comparisons
comparisons
for
¶ between
comparisons between
BMI
between
¶ BMI groups;
groups;
BMI
Overweight Obese ⱡ
DifferencesDifferences
ⱡ
between between
means means
ƚ were were performed
performed using t-tests; ƚ Cuzick’s
using ƚ Cuzick’s
t-tests;trend trend test; statistically
test; statistically significant significant
results are results
in bold.are in bold.
Poverweight Differences
groups; Pobese between
Ptrend means were performed using t-tests; Cuzick’s trend test; statistically significant
Mean ±SD Mean ±SD
results are in bold.
3.1 ±1.1 3.8 ±0.9 0.034 <0.001 <0.001
3.7 ± 3.2 3.9 ± 3.1 0.364standardized
The 0.223 0.100
and adjusted odds ratios for various psychosocial, behavioral, and
2.8 ±0.7 3.5 ±0.6 <0.001 <0.001 <0.001
4.4 ±1.3 6.3 ±1.6
socio-environmental
<0.001 <0.001
factors,
<0.001
by BMI status, among youths in Mexico and the US (controlling for
3.9 ±0.6 4.3 ±0.6age, sex, race/ethnicity,
<0.001 <0.001 and country of residence) are reported in Table 4. Overweight and obese
<0.001
3.1 ±1.1 3.7 ±1.0youth have
0.006 significantly
<0.001 greater odds of reporting body image dissatisfaction (OR = 1.67, OR = 2.95),
<0.001

65.1 ±26.0 having0.045

52.9 ±26.4 depressive symptoms
<0.001 <0.001 (OR = 1.08, OR = 1.12), perceiving themselves as overweight or obese,
and having a lower weight-specific QOL (OR = 0.97, OR = 0.95), than healthy-weight youth. Obese
2.9 ± 0.7 2.8 ± 0.7youth in 0.797 0.723
both countries 0.569 have significantly lower odds of having healthy lifestyle priorities (OR
also
1.6 ± 1.0 1.3 ± 1.0 0.785 0.255 0.176
1.1 ± 0.5 1.0 ± 0.4
= 0.75),0.765
being physically
0.073
active (OR = 0.79), consuming fast food (OR = 0.68), and eating breakfast
0.023
1.6 ± 0.4 1.6 ± 0.4(OR = 0.416
0.47), than0.205 healthy-weight
0.239 youth. Overweight and obese youth are significantly more likely to
1.4 ±0.2 1.4 ±0.2engage0.002 in weight control behaviors (OR = 5.19, OR = 8.88), such as exercise (OR = 1.99, OR = 2.12),
<0.001 0.001
1.8 ±0.4 1.8 ±0.4 0.005 0.003 0.006
1.5 ±0.5 1.6 ±0.5
as well as
0.045
eating0.032less, fewer
0.046
calories, and lower-fat food (OR = 2.15, OR = 2.32) than healthy-weight
1.1 ± 0.3 1.2 ± 0.4youth. In
0.415addition, 0.174overweight
0.168 and obese youth have significantly greater odds of restrained eating
1.0 ± 0.1 1.1 ± 0.2behaviors0.429(OR =0.112 1.86, OR = 2.35) than healthy-weight youth. Both groups are also significantly more
0.058
2.6 ±0.8 2.7 ±0.7 0.001 <0.001 <0.001
likely to perceive their parent as overweight or obese (OR = 1.49, OR = 1.71), and obese youth have
significantly greater odds of reporting that their parents are very concerned about their weight (OR
3.2 ±1.1 3.6 ±1.0 0.0316 <0.001
= 1.56), compared to healthy-weight<0.001 youth. The standardized odds ratio results indicate that the
4.9 ±1.5 5.6 ±1.4 0.0292 <0.001 <0.001
2.6 ± 0.8 2.6 ± 0.7
following
0.1260
psychosocial,
0.1383
behavioral,
0.178
and socio-environmental factors are most significantly associated
2.3 ± 0.8 2.3 ± 0.8with overweight
0.1656 and obesity:
0.1333 0.191 Perceived body shape (OR = 6.31, OR = 25.89), restrained eating
3.0 ± 0.7 0.5642(OR =0.1474
2.9 ± 0.7behaviors 1.7, OR = 0.1032.08), and perceived parent body shape (OR = 1.88, OR = 2.34), respectively.
eference category for comparisons between BMI odds ⱡ
groups;ratios
The standardized of measures with scales that have a wider range, such as the CDI-S
ick’s trend test; statistically significant results are in bold.
(0–20) and the YQOL-W (0–100), show a stronger association with overweight and obesity, than the
non-standardized odds ratios. (Table 4) All the aforementioned results had a p-value of <0.05, which
was considered statistically significant.
 such as exercise and restrainedsuch
eating,
as exercise
as compared
and
Eats restrained
to healthy-weight
breakfast eating, asyouth.
compared
The
1 to 2 only
to 1.7
healthy-weight
statistically
± 0.4 youth. The
1.6 ± 0.4 only statistically
1.6 ± 0.4 0.416 0.205 0.239
es aresignificant
also significantly more likely
socio-environmental to engage
significant
factors inWeight
reported weight
bycontrol
socio-environmental
obesecontrol
behaviors
youthsbehaviors,
factors in both
reported1 to 2by obese
countries 1.2 ± 0.2
includeyouths 1.4 ±
being
in 0.2 countries
both 1.4 ±0.2 include0.002being <0.001 0.001
Exercises 1 to 2 1.5 ± 0.5 1.8 ±0.4 1.8 ±0.4 0.005 0.003 0.006
ned more
eating, as compared
likely to think thattotheir
healthy-weight
parents
more likely toyouth.
are concerned
thinkEatthat
The
about
less, few
only
their their statistically
parents
calories, weight
low-fat are and
concerned
foods that
1 to their
2 aboutparents
1.3 ±their
0.5 have
weight
a ±and
1.5 0.5 that1.6
their
±0.5 parents have a 0.032
0.045 0.046
ental larger
factors body size than
reported byhealthy-weight
obese larger
youthsbody
youth.size
in both However,
than healthy-weight
countries
Fasting overweight
include youths youth.
being However,
in1 tothe
2 US 1.1 are
overweight
not more
± 0.3 youths
1.1 ± 0.3 in the
1.2 ± US
0.4 are not
0.415more 0.174 0.168
likely to report that their parents
likely
areto
concerned
report Diet
that
about pills,their
their powders,
parents or
weight,
areliquids
concerned
as 1 toabout
compared 2 to healthy
1.0 ± 0.0
their weight,
weight1.0
as ± compared
0.1 1.1 ±to
0.2healthy0.429
weight 0.112 0.058
ir parents are concerned about their weight and that their parents have a 1 to 5
Restrained eating behaviors (DEBQ-R) 2.1 ± 0.8 2.6 ±0.8 2.7 ±0.7 0.001 <0.001 <0.001
youths youth.
hy-weight (TablesInt.
2 and 3). Alloverweight
J. Environ.
However, theyouths
Res. aforementioned
(Tables
Public Health 2 and
2019,
youths results
16,
in 3).
theAll
1534 hadUSthe
Socio-environmental
a are
p-value
aforementioned
not of <0.05, which
factorsmore
resultswashadconsidered
a p-value of <0.05, which was considered
9 of 15

arentsstatistically significant.
are concerned about theirstatistically
weight, assignificant.
Perceived parental concern
compared
regarding weight
to healthy weight 1 to 5 2.7 ± 1.2 3.2 ±1.1 3.6 ±1.0 0.0316 <0.001
<0.001
the aforementioned results
Table 2. Comparison
had
Tableof a p-value
Standardized
4.various of Comparison
Table 2.and
<0.05,
psychosocial,
which
Perceived
adjusted
behavioral,parent was
odds
of 7body considered
ofsocio-environmental
15psychosocial,
size
ratios
various
and (PBIA) 1 to 13
for psychosocial, 4.3 ± 1.2
behavioral,
behavioral,
factors by
andBMI and4.9 ±1.5 5.6 ±1.4
factors by0.0292
socio-environmental
socio-environmental BMI <0.001 <0.001
Mother healthy values 1 to 4 2.8 ± 0.7 2.6 ± 0.8 2.6 ± 0.7 0.1260 0.1383
0.178
category among youths
factorsinbyMexicocategory
(n = 181).
BMI status, among
among youths
youth
Father ininvalues
healthy Mexico (n
Mexico and= 181). to 4= 633).2.1 ± 0.6
the US1(n 2.3 ± 0.8 2.3 ± 0.8 0.1656 0.1333
0.191
mean scores for various psychosocial, behavioral, and socio-
Home availability of healthy foods 1 to 4 3.1 ± 0.7 3.0 ± 0.7 2.9 ± 0.7 0.5642 0.1474
0.103
Healthy Overweight Obese Healthy Overweightⱡ Obese
of residence
various and BMI
psychosocial, status. Within
behavioral, andRange * domain of psychosocial
the
socio-environmental factors Range
by * Overweight
BMI Poverweight ⱡ Pobese Ptrend ƚ P
Obese
overweight
ⱡ
Pobese ⱡ Ptrend ƚ
Mean ±SD * AMean higher± score indicates
SD
S_OR Mean ±aSD greater±frequency
Mean SD or agreement;
Mean ±SD S_ORMean
¶ Reference category
±SD for comparisons between BMI groups; ⱡ
nnMexico
Mexico(nand =Psychosocial
181).
the USFactorsare more likely toPsychosocial report being Factors dissatisfied
Differences between means OR were(95% CI) ∞ using t-tests; ƚ Cuzick’s trend
performed OR test;
(95% CI) ∞ significant results are in bold.
statistically
Dissatisfied with Body Image Dissatisfied
1 to 5 with
2.7 ±Body
1.3 Image3.1 ±1.1 1 to3.85 ±0.9 2.7 ± 1.3 0.034 3.1 <0.001
±1.1 <0.001
3.8 ±0.9 0.034 <0.001 <0.001
themselvesDepression asHealthy
overweight
symptoms or Psychosocial
Overweight
(CDI-S) obese, to 20and
0DepressionObese to3.1 have
Factors
symptoms lower
± 3.3 (CDI-S) weight-
3.7ⱡ ± 3.2 0 to3.920 ± 3.1 3.1 ± 3.3 0.364 3.7 ±0.223
3.2 0.100
3.9 ± 3.1 0.364 0.223 0.100
ⱡ ƚ
Range * Dissatisfied 1with Body Image P overweight P
1.74 are
obese P 1.672.2(1.3,
trend
±0.7 3.22<0.001
2.1) * 2.8 <0.001 3.5 ±0.6 2.95 <0.001
(2.3, 3.7) * <0.001
ight youth. However,
Self-perception ±SD overweight
Meanregarding weight or
Mean ±SD Self-perception5obese
toMean ±2.2
SD youths
regarding
± 0.8 in Mexico
weight
2.8 ±0.7 1 to3.55 ±0.6 ± 0.8
<0.001 <0.001
Perceived Body Shape (PBIA) Depression1symptoms toPerceived
13 (CDI-S)
3.0
Body
± 1.5
Shape (PBIA) 4.4 ±1.3 1.29 1 to6.3 1.083.0(1.0,
13 ±1.6 ± 1.5
<0.001 ±1.3 1.44<0.001
1.2) ** 4.4 <0.001 6.3 ±1.6 1.12 <0.001
(1.1, 1.2) * <0.001 <0.001
pressiveBody symptoms than
Weight Description healthy-weight
Self-perception 1 to 5regarding
Body Weight youths,
3.1 weight
±Description
0.9 unlike
3.9 ±0.6 obese
4.75 1 to4.3 6.63
5 ±0.6 3.1(4.3,
± 0.910.3)
<0.001 * ±0.6 15.13
3.9 <0.001 4.3 ±0.627.03 (16.3,
<0.001 <0.001 44.8) * <0.001 <0.001
1 to 5 2.7 ± 1.3 3.1 ±1.1 3.8 ±0.9 0.034 <0.001 <0.001
ely to0 toreport
Feeling Fat
20 depressive
3.1 ± 3.3 symptoms
Perceived1body
3.7 ± 3.2
tothan
Feeling
5 shape healthy-weight
Fat
3.9 ± 3.1
2.4 ± 1.2
0.364
3.1 ±1.1 youths
6.31 1 to3.7
0.223
5 ±1.02.57
0.100
2.4(2.1,
± 1.2
0.006
3.2) * 3.1 <0.001
±1.1 25.89 <0.001
3.7 ±1.0 5.30 (4.1,0.006 6.8) * <0.001 <0.001
Youth weight-related quality of life weight
Body Youth weight-related quality of life3.47
description 4.02 (2.8, 5.7) * 10.77 14.30 (9.4, 21.7) *
nce of todepressive
1 (YQOL-W)
5 2.2 ± 0.8symptoms 2.8 ±0.7 is greater
0 to 100
(YQOL-W) 3.5 ±among
75.8
0.6 ± 28.1 healthy-weight,
<0.001 65.1 ± 26.0 0
<0.001to
52.9
100 ± 26.475.8
<0.001 ± 28.1
0.045 65.1 <0.001
± 26.0 <0.001
52.9 ± 26.4 0.045 <0.001 <0.001
Feeling fat 2.41 1.99 (1.6, 2.5) * 4.29 3.12 (2.5, 3.9) *
1 to 13
xico (3.1, 3.7,Behavioral 3.0 ± 1.5
3.9, respectively) 4.4 ± 1.3
than those 6.3 ± 1.6
in theFactors<0.001 <0.001 <0.001
Factors
Youth weight-related Behavioral
quality ofUS life(2.1, 2.8, 3.2,
1 Healthy
to 5 3.1 ±priorities
lifestyle 0.9 3.9 ±0.6 Healthy1 to 44.3lifestyle
±0.6 0.6 <0.001
2.8 ±priorities 2.9 ± 0.7 <0.001
0.46 1 to2.8 <0.001
0.97
4 ± 0.7 (0.96,
2.8 ± 0.6 0.98) *2.9 ±0.723
0.797 0.7 0.280.569
2.8 ± 0.7 0.95 (0.94,
0.797 0.96) *0.723 0.569
QOL1 Physically
reported
to 5 by
active
overweight
2.4 ± 1.2
(YQOL-W) or obese
3.1 ±1.1 Physically youths
0 to 33.7 ±active
1.0 in Mexico is lower
1.5 ± 1.0 0.0061.6 ± 1.0 <0.001 0 to1.3 <0.001
3 ± 1.0 1.5 ± 1.00.785 1.6 ±0.255
1.0 0.176
1.3 ± 1.0 0.785 0.255 0.176
s. 78.1Fastandfood67.0, respectively). Behavioral
consumption Fast
1 to food
5 Factors
consumption
1.1 ± 0.4 1.1 ± 0.5 1 to1.05 ± 0.4 1.1 ± 0.4 0.765 1.1 ±0.073
0.5 0.023
1.0 ± 0.4 0.765 0.073 0.023
0 toEats
100breakfast
75.8 ± 28.1 65.1 ±26.0 Eats 1 to 52.9 ±26.4
2breakfast 1.7 ± 0.4 0.0451.6 ± 0.4 <0.001
1 to1.6 <0.001
2 ± 0.4 1.7 ± 0.4
0.416
obese youth in the US haveHealthy
lower lifestyle
healthy priorities
lifestyle priorities 0.87 (3.0 0.82 (0.6, 1.1) 1.6 ±0.205 0.4 0.820.239
1.6 ± 0.4 0.75 (0.6,
0.4161.0) ** 0.205 0.239
Weight control behaviors Physically active Weight
1 to 2 control 1.2behaviors
± 0.2 1.4 ±0.2 0.88 1 to1.4 2 ±0.20.881.2 ± 0.2
0.002
(0.7, 1.1) 1.4 <0.001
±0.2 0.790.001 1.4 ±0.2 0.79 (0.6,0.0021.0) ** <0.001 0.001
cally1 activeExercises
to 4
(1.6 vs.
2.8 ± 0.6
1.8, respectively),
Fast food
2.9 ± 0.7
1 to 2 and1.5are
Exercises
consumption 2.8 ± 0.7
± 0.5 less likely
0.797
1.8 ±0.4 to
0.97 1eat
0.723
to1.82 ±0.40.97
0.569
1.5 ± 0.5
0.005
(0.7, 1.3) 1.8 ±0.003
0.4 0.730.006
1.8 ±0.4 0.68 (0.5,0.0050.9) ** 0.003 0.006
Eat less, few calories, low-fat foods 1 toEat
2 less, few1.3calories,
± 0.5 low-fat 1.5foods
±0.5 1 to1.62 ±0.5 1.3 ± 0.5 0.045 1.5 ±0.032
0.5 0.046
1.6 ±0.5 0.045 0.032 0.046
han healthy-weight
0 to 3
Fasting
1.5 ± 1.0 youth 1.6 in
Eats ± 1.0the US.
breakfast
1 to
1.3 ±Overweight
Fasting
2
1.0
1.1 ± 0.3
0.785 and0.87
1.1 ± 0.3
obese
0.255
1 to1.2
0.70 (0.4, 1.2)
0.176
2 ± 0.4 1.1 ± 0.3 0.415 1.1 ±0.174
0.3
0.73
0.168
1.2 ± 0.4
0.47 (0.3, 0.8) **
0.415 0.174 0.168
1 to 5Diet pills,1.1
o significantly ± 0.4 likely
more
powders,
Weight
1.1
or liquids
control
to±engage
0.5 1 toDiet behaviors
21.0
in ± 0.4
weight
pills, 1.0 control
powders,
± 0.0 0.765
or
1.46
± 0.1 0.073
1.0behaviors,
liquids 1 to1.1
5.19
0.023
2 ± 0.2
(2.0,
1.0 ± 0.0
13.2)
0.429
* 1.0 ±0.112
0.1
1.64 0.058
1.1 ± 0.2
8.88 (3.7,
0.429
21.5) * 0.112 0.058
1 Restrained
to 2 1.7 ±behaviors
eating 0.4 Exercises
1.6
(DEBQ-R)± 0.4 Restrained
1 to 51.6 ±eating
0.4 0.8 0.416
2.1 ±behaviors (DEBQ-R)
2.6 ±0.8 1.37
0.205
1 to2.7 1.992.1(1.3,
0.239
5 ±0.7 ± 0.8
0.001 ±0.8 1.41<0.001
3.1) ** 2.6 <0.001 2.7 ±0.7 2.12 (1.4,0.001 3.2) * <0.001 <0.001
ng, as1 tocompared to healthy-weight
2Socio-environmental
1.2 ± 0.2 Eat±less,
1.4
youth.
0.2 few Socio-environmental
calories, The only statistically
1.4 ±0.2 low-fat0.002 <0.001 0.001
factors factors 1.47 2.15 (1.4, 3.3) * 1.52 2.32 (1.6, 3.4) *
ors reported
1 Perceived
to 2 by±obese
1.5
parental concernyouths
0.5 1.8 ±0.4 inPerceived
foods both countries
1.8 ± 0.4
parental include being
0.005
concern 0.003 0.006
1 to 5 2.7 ± 1.2 3.2 ±1.1 1 to3.65 ±1.0 2.7 ± 1.2 0.0316 3.2 <0.001
±1.1 3.6 ±1.0
regarding
ss are1 concerned
to 2 weight
1.3 ± 0.5 Fasting
±0.5 regarding
1.5 weight ±weight
1.6 that
0.5 their0.045 1.00
0.032 a 0.99
0.046 (0.5, 2.0) 1.18<0.001 1.680.0316
(0.9, 3.1) <0.001 <0.001
about their and parents have
1 Perceived
to 2 parent
1.1 ± body Diet
0.3 size (PBIA)
1.1 pills,1Perceived
± 0.3 powders, or ±liquids
to 131.2 ±parent
4.3
0.4 body
1.2 size0.415 (PBIA)
4.9 ±1.5 0.97 1 to5.6
0.174 13 ±1.4 0.86
0.1684.3 ±(0.3,
1.2 2.6) 4.9 <0.001
0.0292 ±1.5 1.11<0.0015.6 ±1.4 1.640.0292 (0.7, 4.1) <0.001 <0.001
ht youth.
1 Mother
However,
to 2 healthy 1.0 ±values
0.0
overweight
Restrained youths
Mother
1.0 ± 0.1 eating
in2.8the
1 to 41.1behaviors
healthy
± 0.2 ± 0.7US
values are not 0.112
0.4292.6 ± 0.8
more1 to2.64 ± 0.7
0.0582.8 ± 0.7
0.1260 2.6 0.1383
± 0.8 0.178
2.6 ± 0.7 0.1260 0.1383 0.178
1.70 1 to2.3 1.862.1(1.4, ± 0.8 2.080.191
2.4) * 2.3 0.1333 2.3 ± 0.8 2.35 0.1656
(1.8, 3.0)* 0.1333
1 Father
to 5 healthy
e concerned 2.1values
about ± 0.8their (DEBQ-R)
weight,
2.6 ±0.8 as Father
1 tocompared
4 healthy
2.7 ±0.7 2.1values
± 0.6
0.0012.3 ± 0.8weight
to healthy <0.001 4 ± 0.8 <0.001 ± 0.6
0.1656 0.191
Home availability of healthy foods Home
1 to 4 availability
3.1 ± 0.7
of healthy3.0 foods
± 0.7 1 to2.94 ± 0.7 3.1 ± 0.7 0.5642 3.0 0.1474
± 0.7 0.103
2.9 ± 0.7 0.5642 0.1474 0.103
ementioned results had a p-value of <0.05,
Socio-environmental
* A higher score indicates a greater frequency
which
* A higher
factorswas
or agreement;
considered
score indicates
¶ Reference
a greater
category
frequency
for comparisons
or agreement;
between
¶ Reference
BMI groups; ⱡ
category for comparisons between BMI groups; ⱡ
1 to 5 Differences
2.7 ±between
1.2 Perceived
3.2 were parental
±1.1 performed concern
3.6using
±1.0 t-tests;
means Differences ƚ 0.0316
between Cuzick’s
means trend
<0.001
1.15
were test;
performed 1.12
statistically
using (0.9, 1.3)
ƚ Cuzick’s
significant
t-tests; are in 1.76
results trend bold.statistically1.56
test; (1.3, 1.8)
significant * are in bold.
results
regarding weight <0.001
1 to 13 4.3 ± 1.2 4.9 ±1.5 parent5.6
Perceived ±1.4shape 0.0292
body <0.001
1.88 <0.001
1.49 (1.3, 1.7) * 2.34 1.71 (1.5, 2.0) *
sychosocial,
1 to 4 behavioral,
2.8 ± 0.7 and socio-environmental
2.6
Mother± 0.8 2.6 ± 0.7 factors
healthy values 0.1260by BMI 0.1383
0.94 0.178
0.92 (0.7, 1.2) 0.97 0.96 (0.7, 1.2)
1 to
n = 181). 4 2.1 ± 0.6 2.3
Father± 0.8
healthy 2.3
values± 0.8 0.1656 0.1333
0.93 0.191
0.92 (0.7, 1.2) 1.21 1.22 (1.0, 1.6)
1 to 4 3.1 ± 0.7 3.0 ± 0.7
Home availability2.9of± healthy
0.7 0.5642
foods 0.1474
0.94 0.103
0.96 (0.7, 1.3) 0.97 0.98 (0.7, 1.3)
eater Healthy Overweight
frequency or agreement; Reference Obese
category for comparisons ⱡ
Pbetween BMI
Ptrendgroups;
¶ ⱡ ⱡ ƚ
* Standardized odds Poverweight
ratios; Healthy is reference
obese category for comparison between BMI groups; ∞ Adjusted for
Mean ±SD Mean ±SD Mean ±SD
ere performed using t-tests; ƚ Cuzick’s
age, gender,
trend race/ethnicity,
test; statisticallyand * p-value
country;results
significant are in 0.001; ** p-value < 0.05; significant results are in bold.
≤ bold.
2.7 ± 1.3 3.1 ±1.1 3.8 ±0.9 0.034 <0.001 <0.001
0 3.1 ± 3.3 3.7 ± 3.2Table 3.9
5 ± presents
3.1 0.364 0.223 regression
the logistic 0.100 results for the psychosocial, behavioral, and
2.2 ± 0.8 2.8 ±0.7 3.5 ±0.6 <0.001 <0.001 <0.001
3 3.0 ± 1.5
socio-environmental
4.4 ±1.3 6.3 ±1.6
factors,
<0.001
stratified
<0.001
by sex.
<0.001
Some important differences are observed by sex.
3.1 ± 0.9 For
3.9 example,
±0.6 4.3 overweight
±0.6 or obese
<0.001 boys are
<0.001 more likely to report dissatisfaction with their body image
<0.001
2.4 ± 1.2 3.1
(OR±1.1= 1.81 3.7
and OR = 3.21,
±1.0 0.006respectively)
<0.001 <0.001 girls (OR = 1.59 and OR = 2.78, respectively). However,
than
0 75.8 ± 28.1 the
65.1 presence
±26.0 52.9 of depressive
±26.4 0.045 symptoms
<0.001 is<0.001
significantly greater among overweight and obese females
(OR = 1.14 and OR = 1.16, respectively) but not among males. Girls are also more likely to perceive
2.8 ± 0.6 2.9 ± 0.7
themselves 2.8
as±overweight
0.7 0.797or obese
0.723 0.569 fat” (OR = 8.91 and OR = 34.28, respectively) than boys
and “feel
1.5 ± 1.0 1.6 ± 1.0 1.3 ± 1.0 0.785 0.255 0.176
1.1 ± 0.4
(OR = 7.14 1.0
1.1 ± 0.5
and OR = 32.28,
± 0.4 0.765
respectively).
0.073
Obese females are significantly less likely to be physically
0.023
1.7 ± 0.4 active
1.6 = 0.72)
± 0.4 (OR 1.6 ± 0.4 and eat
0.416breakfast healthy-weight females (OR = 0.40), but this association was
0.205than 0.239
1.2 ± 0.2 1.4
not±0.2
found to 1.4 ±
be0.2significant
0.002 among<0.001
males.0.001
Overweight or obese males are more likely to engage in
1.5 ± 0.5 1.8 ±0.4 1.8 ±0.4 0.005 0.003 0.006
1.3 ± 0.5
weight control
1.5 ±0.5
behaviors
1.6 ±0.5
(OR = 0.032
0.045
13.77 and OR = 12.69, respectively) than obese females (OR = 8.02),
0.046
1.1 ± 0.3 especially
1.1 ± 0.3 exercise = 2.67 and
1.2 ± 0.4 (OR0.415 OR = 2.59,
0.174 0.168 respectively) and eating less/few calories/low-fat foods
1.0 ± 0.0 1.0
(OR± 0.1= 3.40 1.1
and OR = 2.93,
± 0.2 0.429respectively).
0.112 0.058
However, obese girls are significantly more likely to consume
2.1 ± 0.8 2.6 ±0.8 2.7 ±0.7 0.001 <0.001 <0.001
diet pills, powders or liquids (OR = 9.59) than boys (Table 5). All the aforementioned results had a
p-value of <0.05, which was considered statistically significant.
2.7 ± 1.2 3.2 ±1.1 3.6 ±1.0 0.0316 <0.001
<0.001
3 4.3 ± 1.2 4.9 ±1.5 5.6 ±1.4 0.0292 <0.001 <0.001
2.8 ± 0.7 2.6 ± 0.8 2.6 ± 0.7 0.1260 0.1383 0.178
2.1 ± 0.6 2.3 ± 0.8 2.3 ± 0.8 0.1656 0.1333 0.191
3.1 ± 0.7 3.0 ± 0.7 2.9 ± 0.7 0.5642 0.1474 0.103
ncy or agreement; ¶ Reference category for comparisons between BMI groups; ⱡ
ed using t-tests; ƚ Cuzick’s trend test; statistically significant results are in bold.
 akfast (1.5, 1.6,breakfast
respectively)
(1.5, 1.6, thanrespectively)
breakfast
healthy-weight (1.5,
than1.6,
youth
breakfast
healthy-weight
respectively)
in the(1.5,US.1.6,
youth
than
Overweight
respectively)
healthy-weight
in the US. and than
Overweight
obese
youth
healthy-weight
in and
the US.
obese
youth
Overweight
in the US.
and Overweight
obese and obese
ticipants in bothparticipants
countries are in both
also countries
significantly
participants
are more
also
in both
significantly
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countries
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are
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both
also
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control
arein
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more
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weight
significantly
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moreinlikely
weight
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control in
behaviors,
weight control behaviors,
h as exercise andsuchrestrained
as exercise eating,
and restrained
as
such
compared
as exercise
eating,
to healthy-weight
and
as
such
compared
restrained
as exercise toyouth.
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healthy-weight
and restrained
The
as compared
only statistically
youth.
eating,
to healthy-weight
The
as compared
only statistically
toyouth.
healthy-weight
The only statistically
youth. The only statistically
nificant socio-environmental
significant socio-environmental
factors significant
reported by factors
socio-environmental
obesesignificant
reported
youths by insocio-environmental
both
obese
factors
countries
youths
reported
ininclude
both
by
factors
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obese
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youths
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obese
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youths ininclude
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being include being
re likely to think
more
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think that
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think
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parents
and
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parents
andabout
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aconcerned
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weightabout
have
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parents
and that
havetheir
a parents have a
7 of 15
ger body size thanlargerhealthy-weight
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Int. J.size thanyouth.
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larger However,
bodyHealth
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than
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2019,healthy-weight
However,
body
16, youths
1534sizeoverweight
than
in youth.
the
healthy-weight
USHowever,
youths
are notinmoreyouth.
overweight
the USHowever,
are not
youths
more
overweight
in the USyouths
are notinmore
the US10are
of not
15 more
ly to report thatlikely
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to parents
report that are concerned
their
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parents
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report
are their
concerned
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to parents
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report
as compared
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that
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their
weight,
toparents
healthy
as about
compared
are
weight
their
concerned
toweight,
healthy
about
asweight
compared
their weight,
to healthy
as compared
weightto healthy weight
us (Tables
uths psychosocial,
2 and
youths behavioral,
3). All
(Tables
the aforementioned and
All thesocio-
2 and 3).youths (Tables
results
aforementioned
had
2 and
youths
a p-value
3). All
(Tables
results
the
of aforementioned
<0.05,
had
2 and awhich
p-value
3). Allwas
the
ofresults
aforementioned
considered
<0.05, had
which a p-value
wasresults
considered
of <0.05,
had awhich
p-value was
of considered
<0.05, which was considered
isticallyWithin
status. significant.
statistically
the domain significant. statistically significant.
of psychosocial statistically significant.
Table 5. Association between psychosocial, behavioral, and socio-environmental factors and overweight
re more likely to reportorbeing obesity, dissatisfied = 633).
Table 2. Comparison Table
of various
2. Comparison
psychosocial, ofby sex
various
Table (npsychosocial,
behavioral,
2. Comparison
and Table
socio-environmental
of
behavioral,
various
2. Comparisonpsychosocial,
and socio-environmental
factors
of various
behavioral,
by BMI psychosocial,
and
factors
socio-environmental
behavioral,
by BMI and socio-environmental
factors by BMI factors by BMI
ght or obese,
category among youthsand to
category have
among(nlower
in Mexico youths weight-
= 181).incategory
Mexico among (n = 181). youths
categoryin Mexico
among(nyouths = 181).in Mexico (n = 181).
Female Male
overweight or obese youths in Mexico Healthy are
Overweight Healthy Obese Overweight Healthy
ⱡ Obese ⱡ Overweight Healthy Obese
ƚ ⱡ ⱡ Overweight ⱡ Obese ⱡ ƚ ⱡ ⱡ
Range * Range * Range
OverweightP*
overweight P Range
obese P *P
Obese
overweight
trend obese P P Pƚ
Overweight
trend overweight obese P P P
Obese
overweight
trend obeseP P
trendƚ

an healthy-weight youths, unlike Mean ±SDobese Mean ±MeanSD ±Mean SD ±Mean SD ±SD Mean
OR (95% CI)
Mean
∞
±±SD
SD Mean ±Mean
OR (95%
SD ∞±Mean
CI)
SD ±Mean SD ±SD
OR (95% CI)
Mean
∞
±SD
OR (95% CI) ∞
Psychosocial Factors Psychosocial Factors Psychosocial Factors Psychosocial Factors
e symptoms
ssatisfied than healthy-weight
with Body Dissatisfied
Image with Body
1 to 5Image Psychosocialyouths
Dissatisfied
2.7 ± 1.3 1 with
to 53.1Body
Factors ±1.1Dissatisfied
Image
2.7 ± 1.3 3.8 ±with
0.93.1Body
1± to1.1
5Image
0.034 2.73.8±±1.3
<0.001
0.9 1 to 53.1 0.034
<0.001
±1.12.7 ± 1.3<0.001
3.8 ±0.93.1<0.001
±1.1 0.034 3.8 ±<0.001
0.9 0.034
<0.001 <0.001 <0.001
pression symptoms (CDI-S)
Depression symptoms 0 to 20(CDI-S)
Body imageDepression
3.1 ± 3.3 0 symptoms
to 20
dissatisfaction 3.7 ± 3.2(CDI-S)
Depression
3.1 ± 3.3 3.9 ±symptoms
3.13.7
1.590 to
±(1.2,
3.2
20(CDI-S)
0.364 3.1
2.2) ** 3.9±±3.3
3.1
0.22302.78
to 203.7
0.364
0.100
± 3.2
(2.0, 3.1 ±*3.3
3.8) 0.223
3.9 ± 3.13.70.100
1.81 ±(1.3,
3.2 0.364
2.5) *3.9 ± 3.1
0.2233.21 (2.3,
0.364
0.1004.5) * 0.223 0.100
ptoms is greater
f-perception regarding among
Self-perception
weight regardinghealthy-weight,
1 to 5 weight Self-perception
2.2 ± 0.8 1 to 52.8 regarding
±0.7Self-perception
2.2weight
± 0.8 3.5 ±0.62.8
regarding
1± to0.7
5<0.001
weight
2.2
3.5±±0.8
<0.001
0.6 1 to 52.8
Depression symptoms (CDI-S) 1.14 (1.0, 1.3) ** 1.16 <0.001
<0.001
±0.72.2 ± 0.8
(1.1, 1.3) * <0.001
3.5 ±0.62.8<0.001
1.00 ±0.7<0.001 3.5 ±<0.001
(0.9, 1.1) 0.6
1.07 <0.001
<0.001
(0.97, 1.2) <0.001 <0.001
ctively)
Perceived Body thanShapethose
(PBIA)
Perceived inBodythe
1 to US(PBIA)
Shape
13
Self-perception (2.1, 2.8,1 to3.2,
3.0Perceived
± 1.5
regarding
Body
134.4 ±
Shape
1.33.0(PBIA)
weight
Perceived
± 1.5 6.3 ±1.6
Body
4.4
1 to
±
Shape
1.3
13<0.001
(PBIA)
8.91 (4.5, 17.5) *
3.0
6.3±±1.5
<0.001
1.6 1 to 13 4.4
<0.001
<0.001
±1.33.0 ± 1.5
34.28 (16.1, 73.1) *
<0.001
6.3 ±1.64.4<0.001
±1.3<0.001 6.3 ±<0.001
7.14 (3.7, 13.9) *
1.6 <0.001
<0.001
32.28 (15.1, 69.0) *
<0.001 <0.001
Body Weight Description Body Weight Description
1 to 5 3.1Body
± 0.9 Weight
1 to 53.9Description
±0.63.1Body
± 0.9 4.3
Weight
±0.63.9
Description
1± to0.6
5<0.001 3.14.3±±0.9
<0.001
0.6 1 to 53.9 <0.001
<0.001
±0.63.1 ± 0.9<0.001
4.3 ±0.63.9<0.001
±0.6<0.001 4.3 ±<0.001
0.6 <0.001
<0.001 <0.001 <0.001
weight
Feeling Fat or obese youths
Feeling Fat Perceived
1into 5Mexico body
± is shape
1.2 lower
2.4Feeling Fat
1 to 53.1 ±1.12.4Feeling
± 1.2 3.7Fat 3.43
±1.03.11± (2.4,
to1.1 4.9) *
5 0.006 2.43.7±±1.2
<0.0017.07
1.0 1 to 53.1(4.7,
0.006 10.6)
<0.001 *
±1.12.4 ± 1.2<0.001 2.16
3.7 ±1.03.1 (1.7,
<0.001 2.8) *
±1.1 0.006 3.7 ±<0.001
1.0 4.45 (3.2,
0.006
<0.0016.1) * <0.001 <0.001
uth weight-related quality
Youth ofweight-related
life Body weight
quality of Youth description
life weight-related quality Youth of 4.45
weight-related
life (2.7, 7.3) *
quality of life 12.94 (7.3, 23.0) * 3.87 (2.3, 6.4) * 17.37 (9.2, 32.7) *
tively).
QOL-W) (YQOL-W)
0 to 100
Feeling fat 75.8 ± 28.1
(YQOL-W)
0 to 100
65.1 ± 26.0
75.8 ± 28.1
(YQOL-W)
52.9 ± 26.4
65.10 to
± 26.0
100 0.045
2.02 (1.5, 2.7) * 75.8
52.9 ±±28.1
<0.001
26.40 to 100
65.1
0.045
<0.001
± 26.0
75.8
3.15 (2.3, 4.3) * ± 28.1
<0.001
52.9 ± 26.4
65.1
<0.001
± 26.00.045
2.25 (1.6, 3.1) * 52.9 ±<0.001
26.4 0.045
<0.001
3.53 (2.5, 4.9) * <0.001 <0.001

have lower healthy lifestyle priorities (3.0

Behavioral Factors BehavioralYouth weight-specific
Factors quality
Behavioral of life
Factors Behavioral Factors
0.96 (0.95,0.98) * 0.95 (0.93, 0.96) * 0.98 (0.96, 0.99) ** 0.96 (0.94, 0.97) *
Healthy lifestyle(YQOL-W)
althy lifestyle priorities priorities
1 to 4 Healthy
2.8 ± 0.6 lifestyle
1 to 42.9 priorities
± 0.7Healthy
2.8 ± 0.6 2.8
lifestyle
± 0.72.9
priorities
1±to0.74 0.797 2.82.8±±0.6
0.7
0.7231 to 42.9 0.797
0.569
± 0.72.8 ± 0.60.723
2.8 ± 0.72.90.569
± 0.7 0.797 2.8 ± 0.70.723 0.797
0.569 0.723 0.569
, respectively),
ysically active andactive
Physically are0 toless 3 likely
1.5 ± 1.0 toactive
Physically eat
0 to 31.6 ± 1.0Physically
1.5 ± 1.0 1.3active
± 1.01.60±to1.03 0.785 1.51.3±±1.0
1.0
0.2550 to 31.6 0.785
0.176
± 1.01.5 ± 1.00.255
1.3 ± 1.01.60.176
± 1.0 0.785 1.3 ± 1.00.255 0.785
0.176 0.255 0.176
Behavioral Factors
st food consumption Fast food consumption 1 to 5 Fast
1.1 ±food
0.4 consumption
1 to 51.1 ± 0.5Fast
1.1 ±food
0.4 1.0consumption
± 0.41.11±to0.55 0.765 1.11.0±±0.4
0.4
0.0731 to 51.1 0.765
0.023
± 0.51.1 ± 0.40.073
1.0 ± 0.41.10.023
± 0.5 0.765 1.0 ± 0.40.073 0.765
0.023 0.073 0.023
uth in
s breakfast
the US. Overweight
Eats breakfast Healthy1 to 2
and
lifestyle
Eats
obese
priorities
1.7 ± breakfast
0.4 1 to 21.6 ± 0.4Eats
1.7 ± breakfast 0.59
0.4 1.6 ± 0.4 1.61±(0.4,
to0.4 0.9) **
2 0.416 1.7 0.20510.75
1.6±±0.4
0.4 to 21.6(0.5,
± 0.41.1)
0.416
0.239 1.7 ± 0.4 1.6 ± 0.41.16
0.205 1.60.239(0.8,
± 0.4 1.8) 1.6 ± 0.4
0.416 0.205 0.760.416
(0.5,
0.239 1.1) 0.205 0.239
Physically active 1.4 ±0.20.76 (0.6, 1.0)1.2 0.2 0.72 (0.5, 0.9)
1.2 ** 1.4 ±0.21.01 (0.7, 1.4) 1.4 ±<0.001
0.2 0.870.002(0.7,
0.001 1.1) <0.001
ely to engage
ight control behaviors in weight
Weight 1control
control behaviors
to 2 behaviors,
Weight
1.2 ± 0.2control
1 to 2behaviors
1.4 ±0.2Weight
1.2 ± 0.2control behaviors
1.41± to0.2
2 0.002 1.4±±0.2
<0.001 1 to 21.40.002
0.001
±0.2 ± 0.2
<0.001 1.40.001
±0.2 0.002 0.001
Exercises Exercises Fast
1 to 2food consumption
1.5Exercises
± 0.5 1 to 21.8 ±0.41.5Exercises 1.12
± 0.5 1.8 ±0.41.8 1± (0.8,1.7)
to0.4
2 0.005 1.5 0.00310.76
1.8±±0.5
0.4 to 21.8(0.5,
±0.41.1)
0.005
0.006 1.5 ± 0.5 1.8 ±0.40.85
0.003 1.80.006(0.6,
±0.4 1.3) 1.8 ±0.4
0.005 0.0030.63 (0.4,
0.0060.9) ** 0.003
0.005 0.006
althy-weight youth.
Eat less, few calories, low-fat
Eat less,
foods The
few 1 toonly
Eats
calories, low-fatstatistically
2breakfast 1.3
foods
Eat
± 0.5
less, few
1 to calories,
21.5 ±0.5low-fat
1.3Eat
± 0.5
less,
foods
1.6few 0.51
±0.5calories,
1.51± (0.2,
to0.5 1.1)1.3
2low-fat
0.045 foods 0.0320.40
1.6±±0.5
0.5 (0.2,
1 to 21.50.045
0.0460.8)
±0.5 1.3 **
± 0.5 1.6 ±0.50.90
0.032 1.50.046(0.4,
±0.5 2.0) 1.6 ±0.5
0.045 0.032 0.500.045
(0.2,
0.046 1.0) 0.032 0.046
Fasting Fasting Weight
1 to 2 control ±behaviors
1.1Fasting
0.3 1 to 21.1 ± 0.31.1Fasting± 0.3 1.2 ± 0.43.00
1.11±to(0.9,
0.3 10.5)1.1
2 0.415 1.2±±0.3
0.4
0.174 1 to 21.1
8.02 0.415
0.168
(2.4,± 0.31.1 ±*0.3
26.8) 0.174
1.2 ± 0.41.10.168
13.77 ±(3.2,
0.3 0.415
59.2)1.2
* ± 0.4
0.174 0.415
0.16849.2) *0.174
12.69 (3.3, 0.168
youths in both
Diet pills, powders, or liquids
countries
Diet pills, powders,
1 Exercise
include
to 2or liquids1.0Diet
being
± 0.0pills,
1 topowders,
21.0 ± 0.1or
1.0liquids
Diet
± 0.0pills,
1.1 ± 0.2
powders,
1.01±to0.1
1.64 2or
0.429
(0.9, liquids
3.0)1.0
1.1±±0.0
0.2
0.1121.88
1 to 21.00.429
0.058
± 0.1
(1.1, 1.0 **
3.4) ± 0.00.112
1.1 ± 0.21.00.058
2.67 ±(1.4,
0.1 0.429
5.2) **1.1 ± 0.2
0.1122.59 (1.4,
0.429
0.0584.7) ** 0.112 0.058
their weight
trained eating behaviorsand that
Restrained
(DEBQ-R) eatingtheir
behaviors
1 Eat parents
to 5 less,
(DEBQ-R)
few 0.8have
Restrained
2.1 ±calories,
eating abehaviors
1 to low-fat
52.6 ±0.8Restrained
2.1(DEBQ-R)
± 0.8 2.7eating
foods ±0.71.53
2.6
behaviors
1± to0.8
5 0.001
(0.9, (DEBQ-R)
2.7)2.1
2.7±±0.8
<0.001
0.7 2.00
1 to 52.60.001
<0.001
±0.8
(1.2, 2.1 **
3.4) ± 0.8
<0.001
2.7 ±0.7 2.6
<0.001
3.40 ±(1.8,
0.8 0.001
6.5) *2.7 ±<0.001
0.7 2.93 (1.6,
0.001
<0.0015.4) * <0.001 <0.001
Socio-environmental factors
Socio-environmental Fasting factors Socio-environmental factors Socio-environmental
0.93 (0.4,factors
2.4) 1.77 (0.8, 4.0) 1.24 (0.4, 3.9) 1.67 (0.6, 4.6)
erweight
ceived parental youths
concern
Perceived inparental
the concern
US arePerceived not more parental concern Perceived parental concern
1 Diet
to 5 pills,2.7 powders,
± 1.2 1 to or53.2
liquids
±1.12.7 ± 1.2 3.6 ±1.0 4.16
3.21± (0.4,
to1.1 38.6)2.7
50.0316 1.0 9.59
3.6±±1.2
<0.001 1 to 5(1.2,
3.2
0.031676.7)
±1.1 2.7 ±**
1.2 3.6 ±1.00.41
<0.001 3.2 ±1.1(0.1, 2.2) 3.6 ±<0.001
0.0316 1.0 0.540.0316
(0.1, 2.0) <0.001
rarding weight
weight, as
ceived parent body size
regarding weight
compared
Perceived
(PBIA)parent 1body
to healthy
Restrained
regarding weight
eating
to 13size (PBIA)
weight
Perceived
behaviors
4.3 ± 1.2 parent
1 to 13 4.9body
regarding weight
±1.5size
Perceived
4.3 ±(PBIA)
1.2 5.6parent
±1.4 4.9
1.691body
to
± 1.5
13size
(1.2,0.0292
(PBIA)
2.4) 4.3
**5.6±±1.2
<0.001
1.4 12.76
to 134.9
<0.001
0.0292
<0.001
±1.5
(1.9, 4.3 ±*1.2
4.0) <0.001
5.6 ±1.4
<0.001
4.9
<0.001
2.22 ±(1.5,
1.50.0292
3.3) *5.6 ±<0.001
<0.001
1.4 2.11 0.0292
<0.0013.0) * <0.001
(1.5,
<0.001
<0.001
(DEBQ-R)
a p-value
other of Mother
healthy values <0.05, which
healthy 1 to 4was considered
values Mother
2.8 ± 0.7healthy
1 to 42.6
values
± 0.8Mother
2.8 ± 0.7healthy
2.6 ± 0.72.6
values
1±to0.840.1260 2.82.6±±0.7
0.1383
0.7 1 to 42.6 0.1260
0.178
± 0.82.8 ± 0.7
0.1383
2.6 ± 0.72.60.178
± 0.80.1260 2.6 ± 0.1383
0.7 0.1260
0.178 0.1383 0.178
her healthy values Father healthy values
1 to Socio-environmental
4 Father
2.1 ± 0.6healthy
1 to values
42.3 ± 0.8Father
Factors2.1 ± 0.6healthy
2.3 ± 0.8values
2.31±to0.8
40.1656 2.1
2.3±±0.6
0.1333
0.8 1 to 42.3
0.1656
0.191
± 0.82.1 ± 0.6
0.1333
2.3 ± 0.82.30.191
± 0.80.1656 2.3 ± 0.1333
0.8 0.1656
0.191 0.1333 0.191
me availability of healthy
Homefoods
availability1oftohealthy
4
Perceived foods
Home
3.1 ± 0.7
parental availability
1 to 43.0of
concern ±regarding
0.7
healthy
Home
3.1 ± 0.7
foods
availability
2.9 ± 0.73.01of
±to0.7
healthy
40.5642foods
3.1
2.9±±0.7
0.1474
0.7 1 to 43.0
0.5642
0.103
± 0.73.1 ± 0.7
0.1474
2.9 ± 0.73.00.103
± 0.70.5642 2.9 ± 0.1474
0.7 0.5642
0.103 0.1474 0.103
1.03 (0.8, 1.3) 1.50 (1.2,
ⱡ 1.9) * 1.21
ⱡ (0.9, 1.5) 1.61 (1.3, 2.0) *
* A higher score indicates
* Aahigher weight
greaterscore
frequency
indicates
or agreement;
a greater
* A higher
frequency
¶ Reference
scoreor
indicates
agreement;
category
* Aahigher
greater
for¶ comparisons
Reference
score
frequency
indicates
category
between
or agreement;
a greater
forBMI
comparisons
groups;
frequency
Reference
between
or agreement;
category
BMIfor
groups;
¶ comparisons
¶ Reference category
between
forBMI groups; between BMI groups; ⱡ
comparisons ⱡ

Differences between means

Differences Perceived
were performed
between parent
means
using body
t-tests;
were size
Differences
performed
Cuzick’s
between
using ƚ
trend t-tests;
test;
means
Differences 1.47
statistically
were
Cuzick’s (1.2, test;
performed
between 1.8)
significant
trend ƚ
means
using * t-tests;
results
statistically
wereare 1.67
performed(1.4,
Cuzick’s
insignificant
bold. 2.0)
using
trend * are
results ƚ
t-tests;
test; 1.56significant
statistically
Cuzick’s
in bold. (1.3, test;
trend 1.9)results
*ƚ
statistically1.83
are in (1.5, 2.3)
significant
bold. * are in bold.
results
and socio-environmental factors by BMI
Mother healthy values 0.83 (0.6, 1.2) 0.81 (0.6, 1.2) 1.00 (0.7, 1.4) 1.12 (0.8, 1.6)
Father healthy values 0.78 (0.5, 1.1) 1.33 (0.9, 1.9) 1.05 (0.7, 1.6) 1.06 (0.7, 1.5)
Home availability of healthy foods 0.95 (0.6, 1.4) 0.96 (0.7, 1.4) 0.94 (0.6, 1.4) 0.99 (0.7, 1.5)
ht Obese
Poverweight ⱡ Healthy
Pobeseisⱡ reference
Ptrend ƚ category for comparison between BMI groups; ∞ Adjusted for age, race/ethnicity, and country;
D Mean ±SD
* p-value ≤ 0.001; ** p-value < 0.05; statistically significant results are in bold.
3.8 ±0.9 0.034 <0.001 <0.001
3.9 ± 3.1 4. Discussion
0.364 0.223 0.100
3.5 ±0.6 <0.001 <0.001 <0.001
6.3 ±1.6 <0.001 The <0.001
primary<0.001
objective of thisstudy was to examine the relevance of various psychosocial,
4.3 ±0.6 <0.001 <0.001
behavioral, <0.001
and socio-environmental factors among overweight and obese youth in the US and Mexico,
3.7 ±1.0 0.006 <0.001 <0.001
and to determine differences by sex. We aimed to address gaps in the current research by studying
0 52.9 ±26.4 0.045
factors in<0.001distinct<0.001
domains among an ethnically diverse, bi-national sample of youth. Our results
support the findings of other studies in the US that have examined similar factors within these three
2.8 ± 0.7 0.797 0.723 0.569
1.3 ± 1.0
domains [13–36].
0.785 0.255
However,
0.176
as far as we know, our study is the first to explore the effects of multiple
1.0 ± 0.4 psychosocial
0.765 0.073factors,
0.023behavioral, and socio-environmental factors on overweight or obesity risk in a
1.6 ± 0.4 0.416
diverse sample 0.205 of youth.
0.239 By simultaneously examining all of these factors in one sample, we were able
1.4 ±0.2 0.002 <0.001 0.001
1.8 ±0.4
to contrast
0.005
the relevance
0.003 0.006
of different risk factors in a single large group, rather than across various
1.6 ±0.5 studies, which
0.045 0.032 may be difficult to compare. Additionally, to the best of our knowledge, this is one of the
0.046
1.2 ± 0.4 0.415
first studies 0.174
to shed0.168
light on the association between psychosocial, behavioral, and socio-environmental
1.1 ± 0.2 0.429 0.112 0.058
2.7 ±0.7 factors and
0.001 the presence
<0.001 <0.001 of overweight or obesity among youth in Mexico and Latinos living in the US.
In our study, psychosocial factors, such as a higher rate of body image dissatisfaction, depressive
3.6 ±1.0 symptoms,
0.0316 <0.001self-perception of overweight, and a lower weight-related QOL, were most strongly
<0.001
5.6 ±1.4
associated
0.0292
with
<0.001
overweight
<0.001
or obesity. These results are consistent with other studies, which
2.6 ± 0.7 found
0.1260 a higher
0.1383 prevalence
0.178 of these factors among overweight or obese youth, as compared to
2.3 ± 0.8 0.1656 0.1333 0.191
healthy-weight youth [13–15,17,19,20]. We found that depressive symptoms are significantly associated
2.9 ± 0.7 0.5642 0.1474 0.103
with overweight or obesity among girls but not boys. Inconsistent gender differences have previously
category for comparisons between BMI groups; ⱡ
been reported for the relationship between depressive symptoms and obesity [14,17]. These mixed
d test; statistically significant results are in bold.
results could be attributable to variations in study design or assessment of depression [54], or due to
the characteristics of the study sample. A meta-analysis of 17 studies concluded that depression is
positively associated with BMI but only among females [54]. Interestingly, overweight or obese youths
Int. J. Environ. Res. Public Health 2019, 16, 1534 11 of 15

in Mexico did not report more depressive symptoms than healthy-weight youths, unlike obese youths
in the US, who did report more depressive symptoms than healthy-weight youths. Our findings also
indicate a higher prevalence of depressive symptoms among youths in Mexico than in the US.
In terms of self-perception regarding weight, overweight or obese girls were more likely to
perceive themselves as overweight or obese than boys. Similar differences have been observed with
adolescent girls being more likely to perceive themselves as overweight or obese than boys [13].
A recent study investigated brain activation using functional magnetic resonance imaging during a
body perception task in healthy males and females. They found that images of their own bodies were
more salient for the female participants and concluded that females may be more vulnerable than
males to conditions involving own body perception [55]. Youths in Mexico reported higher scores for
all the “self-perception regarding weight categories”, than youths in the US. Obese adolescents have
been shown to report a lower QOL [20], which was also found in this study, with overweight or obese
youth reporting significantly lower weight-related QOL than healthy-weight youth. Additionally, the
weight-related QOL reported by overweight or obese youths in Mexico was lower than in the US.
Notably, self-reported QOL is lower in Mexico than in the US., regardless of weight status.
The multivariate analyses indicate that obese youth were less likely to have healthy lifestyle
priorities, be physically active, or eat breakfast. However, when stratified by sex, only obese females
were significantly less likely to engage in physical activity. Obese and overweight youth were twice as
likely to report that they exercise for weight control, compared to healthy weight youths. There are
contradictory findings regarding the effect of physical activity by gender, with one study showing a
protective effect only among boys [14] and another only among girls [22]. By contrast, eating breakfast
has shown a consistent protective effect for boys and girls in various studies, across different ethnic
groups [14,26,27]. Our results also indicate that obese youth are less likely to consume breakfast, but
when stratified by sex, this association only remained significant among obese females.
We found that obese males are less likely to report that they eat fast food, as compared to
healthy-weight males. Additionally, overweight or obese youths in Mexico are less likely to eat fast
food than their counterparts in the US. Previous studies have reported a negative association between
eating fast food and obesity among males [27] and females [14,27]. However, other researchers have
found that fast food consumption is associated with increased risk of obesity [28,29]. When relying
on self-reported behaviors, there may be a higher likelihood of over reporting of socially desirable
behaviors, which could explain the inverse association between fast food consumption and obesity
observed in this study. Several weight control behaviors were also significantly associated with
overweight and obesity in this study. There was a stronger association between weight control
behaviors and BMI among males compared to females. Unhealthy weight control behaviors have been
shown to predict weight gain in boys and girls [14,15,17,22]. Restrained eating was also found to be a
risk factor for obesity in our study, which has previously been reported in other studies [17].
Socio-environmental factors were found to have the least significant associations with overweight
or obesity. In this study, obese youth were more likely to believe that their parents are concerned about
their weight, which has been previously reported in the literature [14,36]. Parental obesity has also
been examined in various studies because children of obese parents may be at greater risk for obesity
due to shared genetic and environmental factors [17,56]. In this study, youth who perceived their
parents as heavier were more likely to be overweight or obese. Although parental health values and the
availability of healthy foods at home have been reported to be significant in other studies [30,31,34,35],
no significant associations were found in this study.
This study has some limitations, including that it is cross-sectional, and thus, no conclusions
about the direction of causality can be made and there is a possibility of reporting bias. Participants
were recruited by means of convenience sampling and might not be representative of their respective
weight groups. Additionally, this is an exploratory study with a limited sample size for the participants
in Mexico. Future studies should be conducted with a larger sample size that will allow for a
higher significance threshold to be set for individual comparisons to compensate for the number of
Int. J. Environ. Res. Public Health 2019, 16, 1534 12 of 15

inferences being made. Other limitations include the specific measures that were collected using a
self-reported questionnaire, a lack of validated measures, and the fact that some of the behavioral and
socio-environmental indices, e.g., “healthy lifestyle priorities,” “physically active,” “mother/father
healthy values,” or “home availability of healthy foods”, were created based on a limited number of
variables and should be interpreted as preliminary findings. The information provided by the study
participants was of a quantitative nature, so we were unable to determine the reason for some of the
differences observed by sex or country of origin. Future studies should collect more qualitative data to
investigate these differences. A strength of this study is that it explored the issue of overweight and
obesity among an ethnically diverse group of youth in the US and Mexico, including African Americans
and Latinos, who are disproportionately affected by obesity. Additionally, this study examined a
breadth of risk factors that have not been analyzed in a comprehensive and comparative manner.
Although some of the indices we created to measure eating behaviors do not have a high reliability
score, the associations we observed support the expected relationships, especially when obesity is the
main outcome variable. The use of indices in this study to combine various factors also allowed for a
robust analysis of complex concepts.

5. Conclusions
The results of this bi-national study highlight some of the differences and similarities in
various psychosocial, behavioral, and socio-environmental factors among a multiethnic sample
of healthy-weight, overweight, and obese youths. We hope our findings help to demonstrate the
importance of considering a wide range of risk and protective factors for obesity among adolescents,
when planning future studies and interventions. Additionally, our results support the need for
multifactorial approaches when developing interventions to address the growing problem of obesity
among youth in the US and Mexico. Intervention programs should use an integrated approach that
addresses several of these factors to help to reduce the alarmingly high rates of obesity among youth in
the US and Mexico. More research is needed on how these factors may interact with each other to cause
obesity, since many are interrelated. Our study paves the way for future studies to focus on adopting a
transdisciplinary approach to identify and address important risk factors for obesity among youth.

Author Contributions: Conceptualization, Y.N.F., L.S.M., N.S., and D.L.P.; Data curation, Z.A.C. and P.R.-P.;
Formal analysis, Z.A.C. and P.R.-P.; Funding acquisition, Y.N.F., L.S.M., J.S., and D.L.P.; Investigation, Y.N.F.,
L.S.M., T.C.E., and D.L.P.; Methodology, Y.N.F., Z.A.C., P.R.-P., L.S.M., T.C.E., K.G.-C., N.S., and D.L.P.; Project
administration, Y.N.F., L.S.M., T.C.E., and D.L.P.; Resources, Y.N.F., L.S.M., J.S., and D.L.P.; Software, Z.A.C. and
P.R.-P.; Supervision, Y.N.F., L.S.M., T.C.E., and D.L.P.; Writing—original draft, Y.N.F., and Z.A.C.; Writing—review
and editing, Y.N.F., Z.A.C., P.R.-P., L.S.M., T.C.E., K.G.-C., J.S., C.M.L., and D.L.P.
Funding: This study was supported by a grant from the National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK) awarded to Patrick (grant number R01DK071101-01A2), and an NIDDK Research Supplement
to Promote Diversity in Health-Related Research Grant awarded to Flores (grant number: 3R01DK071101-02S1).
Contreras received a grant from the Drabkin–Neumann Internship at UCLA to support her work on this study.
Flores was also supported by NIH/NCI K07CA197179. Additional funding was provided by the Epidemiological
and Health Services Research Unit of the Mexican Institute of Social Security.
Conflicts of Interest: The authors declare no conflict of interest.
Compliance with Ethical Standards: All procedures performed in this study were in accordance with the ethical
standards of the institutional research committees and with the 1964 Helsinki declaration and its later amendments
or comparable ethical standards. The Institutional Review Boards of the University of Washington, the University
of California, Los Angeles, and the Mexican Institute of Social Security approved all study materials, including the
study questionnaire, protocol, and consent forms. Informed consent was obtained from all individual participants
included in the study.

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Shelly Festilia Agusanty, dkk: Faktor risiko sarapan pagi dan makanan selingan terhadap kejadian overweight

Volume 10 No. 03 Januari • 2014 Halaman 139-149

Faktor risiko sarapan pagi dan makanan selingan terhadap kejadian

overweight pada remaja sekolah menengah atas
Breakfast and snacking as risk factors of overweight in senior high school
Shelly Festilia Agusanty1, Istiti Kandarina2, I Made Alit Gunawan3

ABSTRACT
Background: Overweight or obesity during childhood and adolescence are important risk factors for the presence of adult overweight or
obesity. Eating habits in childhood and adolescence influence their healthy condition. Prospective studies of breakfast habits and nutritional
status suggest an inverse (protective) association between the frequency of eating breakfast and the risk for overweight and obesity and
relationships between no breakfast and increasing body weight. Objective: To examine risk factor of breakfast and snacking related to
overweight status in adolescents. Method: This was observational study with case control design. First step of study was screening to
have prevalence of overweight in adolescents. The second step was case control study participated by 100 overweight adolescents and 100
normal weight adolescents in senior high school matched in sex, age and school. Data collected were weight and height measurements
for nutritional status, respondent identity and characteristic, breakfast dan snacking habits and physical activity. Statistical analysis
used Chi-Square statistics and multivariable logistic regression analysis. Results: Prevalence of overweight in adolescents were 16,8%.
There were significant association between breakfast with overweight (p<0,05; OR=3.1; 95% CI=1.4-7.47). There was no association
between snacking and overweight, but there were significant association between frequency of snacking (OR=1.9; 95% CI=1.05-3.50),
energy of snacking (OR=2.1; 95% CI=1.13-4.02), and carbohydrate of snacking (OR=4.5; 95% CI=1.94-11.50) with overweight.
In multivariate model, breakfast habits, carbohydrate of snacking and physical activity had significant association with overweight.
Conclusion: Skipping breakfast was a risk factor for overweight in adolescence. Adolescents who had snacking more than twice a day
were having greater risk factor for overweight.

KEY WORDS: breakfast, snacking, overweight

ABSTRAK
Latar belakang: Overweight dan obesitas pada masa anak dan remaja mempengaruhi kejadian overweight dan obesitas pada
masa dewasa. Pola dan perilaku makan pada anak dan remaja mempengaruhi kesehatannya. Beberapa penelitian tentang hubungan
antara perilaku sarapan dan status gizi menunjukkan bahwa dengan meningkatnya frekuensi sarapan pagi dapat menurunkan risiko
overweight dan obesitas serta ada hubungan antara tidak sarapan pagi dengan meningkatnya berat badan. Tujuan: Mengetahui faktor
risiko sarapan pagi dan makanan selingan terhadap kejadian overweight pada remaja SMA. Metode: Jenis penelitian observasional
dengan rancangan kasus kontrol. Tahap awal dilakukan skrining untuk mengetahui prevalensi overweight pada remaja. Jumlah
subjek pada kelompok kasus sebanyak 100 remaja SMA yang overweight dan kontrol sebanyak 100 remaja SMA yang tidak
overweight dengan jenis kelamin, umur, dan asal sekolah yang sama. Data yang dikumpulkan berupa karakteristik subjek, berat
badan dan tinggi badan untuk mengukur status gizi, pola konsumsi sarapan pagi dan makanan selingan serta aktivitas fisik. Data
dianalisis menggunakan uji Chi-Square dan uji regresi logistik. Hasil: Prevalensi overweight kelompok remaja pada penelitian ini
sebesar 16,8%. Sarapan pagi dan kejadian overweight menunjukkan hubungan bermakna (p<0,05; OR=3,1; 95% CI=1,4-7,47).
Sebaliknya, makanan selingan tidak berhubungan dengan kejadian overweight, tetapi ada hubungan antara frekuensi makanan
selingan (OR=1,9; 95% CI=1,05-3,50), energi makanan selingan (OR=2,1; 95% CI=1,13-4,02), dan karbohidrat makanan selingan
(OR=4,5; 95% CI=1,94-11,50) dengan kejadian overweight. Analisis multivariat menunjukkan bahwa sarapan pagi, karbohidrat
makanan selingan, dan aktivitas merupakan variabel yang berhubungan dengan kejadian overweight. Simpulan: Remaja yang
tidak rutin sarapan pagi berisiko menjadi overweight dibandingkan remaja yang rutin sarapan pagi. Remaja yang mengonsumsi
makanan selingan lebih dari dua kali dalam sehari berisiko menjadi overweight dibandingkan remaja yang mengonsumsi makanan
selingan dua kali atau kurang dalam sehari.

KATA KUNCI: sarapan pagi, makanan selingan, overweight

1
Korespondensi: Jurusan Gizi, Politeknik Kesehatan Kementerian Kesehatan Pontianak, Jl. 28 Oktober Siantan Hulu Pontianak, Kalimantan Barat,
e-mail: shellymahira@yahoo.co.id
2
Program Studi S2 Ilmu Kesehatan Masyarakat, Fakultas Kedokteran Universitas Gadjah Mada, Jl. Farmako, Sekip Utara, Yogyakarta 55281,
e-mail: ikandarina@yahoo.com
3
Jurusan Gizi, Politeknik Kesehatan Kementerian Kesehatan Yogyakarta, Jl. Tata Bumi No. 3 Banyuraden Gamping, Sleman, Yogyakarta

Jurnal Gizi Klinik Indonesia, Vol. 10, No. 3, Januari 2014 • 139
 Shelly Festilia Agusanty, dkk: Faktor risiko sarapan pagi dan makanan selingan terhadap kejadian overweight
PENDAHULUAN
Berat badan lebih (overweight) dan obesitas
merupakan masalah kesehatan masyarakat yang perlu
mendapatkan perhatian serius karena merupakan peringkat
kelima penyebab kematian di dunia. Tidak kurang 2,8 juta
orang dewasa meninggal setiap tahunnya disebabkan
oleh overweight dan obesitas (1). Prevalensi overweight
atau gizi lebih di Indonesia mengalami peningkatan
setiap tahunnya. Menurut data Riset Kesehatan Dasar
(Riskesdas), pada tahun 2007 prevalensi overweight
kelompok usia 15 tahun ke atas sebesar 19,1% dan pada
tahun 2010 prevalensi gizi lebih pada kelompok usia
13-15 tahun sebesar 2,5%; kelompok usia 16-18 tahun
sebesar 1,4%; serta prevalensi overweight pada kelompok
usia dewasa (>18 tahun) sebesar 10% dan obes 11,7%.
Prevalensi gizi lebih di Kalimantan Barat pada kelompok
usia 15 tahun ke atas berdasarkan Riskesdas 2007 yaitu
sebesar 13%. Sementara menurut data Riskesdas tahun
2010 menunjukkan prevalensi gizi lebih untuk kelompok
usia 13-15 tahun sebesar 1,5% dan kelompok usia 16-18
tahun sebesar 0,7% sedangkan prevalensi overweight
pada kelompok usia di atas 18 tahun sebesar 8,6% dan
obes 9,5% (2,3).
Overweight dan obesitas pada masa anak dan
remaja mempengaruhi kejadian obesitas pada masa
dewasa (4). Overweight dan obesitas pada masa remaja
juga berpengaruh terhadap timbulnya beberapa penyakit
degeneratif saat dewasa. Penelitian pada anak sekolah
yang overweight menunjukkan bahwa 58% mempunyai
sedikitnya satu faktor risiko penyakit kardiovaskuler
dan 50% mempunyai dua faktor risiko (5). Overweight
pada anak dan remaja dipengaruhi oleh interaksi
kompleks antara faktor genetik dan faktor lingkungan
(6). Selain itu, remaja telah dapat menentukan makanan
yang diinginkannya dan seringkali menjalani pola
makan yang salah seperti tidak sarapan pagi, lebih
memilih mengonsumsi makanan cepat saji, dan sering
mengonsumsi makanan di luar rumah. Kebiasaan ini
menyebabkan remaja mengonsumsi makanan padat
energi dan rendah nilai gizi yang berpotensi timbulnya
overweight (7).
Beberapa penelitian menunjukkan hubungan antara
sarapan pagi dengan status gizi anak sekolah. Penelitian
pada anak usia 5-6 tahun di Selandia Baru menunjukkan
140 • Jurnal Gizi Klinik Indonesia, Vol. 10, No. 3, Januari 2014
bahwa anak yang tidak sarapan pagi mengakibatkan
kenaikan indeks massa tubuh (IMT) (8). Data studi
cross sectional pada anak dan dewasa menunjukkan
bahwa ada hubungan antara tidak sarapan pagi dengan
overweight dan gejala resistensi insulin (9). Beberapa
penelitian sebelumnya tentang hubungan antara perilaku
sarapan dan status gizi menunjukkan bahwa dengan
meningkatnya frekuensi sarapan pagi dapat menurunkan
risiko overweight dan tidak sarapan pagi berhubungan
dengan meningkatnya berat badan (10). Oleh karena
itu, tujuan penelitian ini adalah untuk mengetahui
faktor risiko sarapan pagi dan makanan selingan dengan
kejadian overweight pada remaja sekolah menengah atas
(SMA) di Kota Pontianak.
BAHAN DAN METODE
Penelitian ini adalah penelitian observasional
dengan rancangan penelitian kasus kontrol. Penelitian
dilakukan di Kota Pontianak dengan waktu penelitian
selama 3 bulan yaitu bulan Februari sampai Mei 2013.
Kasus adalah remaja SMA di Kota Pontianak yang
mengalami overweight (IMT/U ≥ persentil ke-85) yang
terdeteksi saat survei sedangkan kelompok kontrol
adalah remaja SMA yang tidak mengalami overweight
dan berstatus gizi baik yang mempunyai jenis kelamin,
umur, dan asal sekolah yang sama dengan kasus. Tahap
awal penelitian adalah melakukan skrining pada sekolah
yang terpilih menjadi tempat penelitian untuk mengetahui
prevalensi overweight pada remaja. Selanjutnya, remaja
yang terpilih menjadi responden akan ditelusuri secara
retrospektif pola makannya yang meliputi sarapan pagi
dan makanan selingan.
Populasi penelitian ini adalah seluruh remaja
SMA baik negeri maupun swasta di Kota Pontianak dan
untuk mengetahui prevalensi overweight pada remaja
SMA di Kota Pontianak maka dilakukan skrining
dengan metode stratified random sampling. Subjek
penelitian merupakan sebagian dari populasi dan diambil
berdasarkan proportional stratified random sampling
dari hasil skrining remaja overweight pada sekolah yang
terpilih. Besar subjek penelitian dihitung berdasarkan
perhitungan besar sampel untuk rancangan kasus kontrol
(11) dengan nilai prevalensi sarapan pagi pada anak
 Shelly Festilia Agusanty, dkk: Faktor risiko sarapan pagi dan makanan selingan terhadap kejadian overweight
obesitas berdasarkan penelitian sebelumnya sebesar
0,44 dan prevalensi sarapan pagi pada anak yang tidak
obesitas sebesar 0,637 (12); tingkat kepercayaan 95%
(Z1-α=1,96; Z1-β =0,842); serta kekuatan penelitian sebesar
80% sehingga jumlah sampel minimal yang dibutuhkan
untuk kasus kontrol adalah masing-masing sebanyak 95
orang.
Subjek yang terpilih berjumlah 100 orang kasus
dan 100 orang kontrol dengan kriteria inklusi kasus adalah
remaja SMA berumur 16-18 tahun yang overweight,
bersedia menjadi sampel penelitian, dan tidak dalam
keadaan sakit saat penelitian dilakukan sedangkan kriteria
inklusi kontrol adalah remaja SMA berumur 16-18
tahun yang tidak overweight, bersedia menjadi sampel
penelitian, dan tidak dalam keadaan sakit saat penelitian
dilakukan. Kriteria eksklusi kasus dan kontrol yaitu
subjek menjalani program diit penurunan berat badan dan
mengonsumsi obat-obatan. Pemilihan kasus dan kontrol
dilakukan matching terhadap umur, jenis kelamin, dan
asal sekolah.
Variabel dalam penelitian ini terdiri dari variabel
terikat yaitu overweight dan variabel bebas yaitu sarapan
pagi, jumlah asupan energi dari sarapan pagi, jumlah
asupan protein dari sarapan pagi, jumlah asupan lemak
dari sarapan pagi, jumlah asupan karbohidrat dari
sarapan pagi, makanan selingan, frekuensi makanan
selingan, jumlah asupan energi dari makanan selingan,
jumlah asupan protein dari makanan selingan, jumlah
asupan lemak dari makanan selingan, dan jumlah asupan
karbohidrat dari makanan selingan. Variabel luar adalah
asupan energi makanan utama dan aktivitas fisik. Data pola
konsumsi sarapan pagi dan makanan selingan diperoleh
dengan melakukan wawancara menggunakan kuesioner
semi quantitative food frequency questionnaire (SQFFQ)
yang memuat frekuensi dan jenis konsumsi sarapan
pagi dan makanan selingan. Kuesioner SQFFQ yang
digunakan dalam penelitian ini merupakan modifikasi
dari kuesioner penelitian sebelumya (13). Jumlah asupan
energi, protein, lemak, karbohidrat dari sarapan pagi dan
makanan selingan diperoleh dengan menggunakan food
recall 24 jam selama 4 hari tidak berturut-turut meliputi 2
hari biasa dan 2 hari libur. Aktivitas fisik diperoleh dengan
menggunakan kuesioner international physical activity
questionnaire (IPAQ) yang telah dimodifikasi.
Overweight diketahui berdasarkan pengukuran
IMT (berat badan dalam kilogram dibagi dengan
kuadrat tinggi badan dalam meter) yaitu apabila IMT
sama dengan persentil ke-85 atau lebih dari baku
rujukan World Health Organization (WHO) 2007
sedangkan dikategorikan tidak overweight apabila IMT
lebih dari persentil ke-5 dan kurang dari persentil ke-
85 dari baku rujukan (14). Data berat badan diperoleh
melalui pengukuran berat badan menggunakan
timbangan injak digital dengan ketelitian 0,1 kg dan
data tinggi badan diperoleh dengan mengukur tinggi
badan menggunakan microtoise. Sarapan pagi adalah
makanan dan minuman yang dikonsumsi di pagi hari
setelah bangun tidur sebelum memulai aktivitas sehari-
hari dan dilakukan tidak melebihi dari jam 10 pagi (10)
yang dikategorikan rutin apabila mengonsumsi sarapan
pagi setiap hari (7 kali seminggu) dan tidak rutin
apabila mengonsumsi sarapan pagi tidak setiap hari
(0-6 kali seminggu). Sementara itu, makanan selingan
adalah makanan dan minuman yang dikonsumsi di
antara makanan utama (sarapan pagi, makan siang,
dan makan malam) termasuk minuman susu, soft drink,
sport drink, dan minuman berenergi (15). Sarapan pagi
harus memenuhi sebanyak 20-25% dari kebutuhan
kalori sehari (16) demikian juga dengan makanan
selingan menyumbang 20-25% dari total kebutuhan
sehari (7).
Berdasarkan angka kecukupan gizi (AKG)
maka kebutuhan energi untuk sarapan pagi dan
makanan selingan masing-masing sebesar 520-650
kkal untuk remaja laki-laki dan 440-550 kkal untuk
remaja perempuan serta dikategorikan tinggi apabila
jumlah asupan lebih dari 650 kkal (laki-laki) atau
550 kkal (perempuan) untuk konsumsi dalam satu
hari. Kebutuhan protein untuk sarapan pagi sebesar
12-15% dari jumlah asupan energi sarapan pagi dan
dikategorikan tinggi apabila jumlah asupan protein
lebih dari 24,4 g (laki-laki) atau 20,6 g (perempuan).
Kebutuhan lemak untuk sarapan pagi sebesar 15-25%
dari jumlah asupan energi sarapan pagi dengan kategori
tinggi apabila jumlah asupan lemak lebih dari 18,1 g
(laki-laki) atau 15,3 g (perempuan). Demikian juga
untuk kategori pada jumlah asupan protein dan lemak
dari makanan selingan. Sementara itu, kebutuhan
Jurnal Gizi Klinik Indonesia, Vol. 10, No. 3, Januari 2014 • 141
 Shelly Festilia Agusanty, dkk: Faktor risiko sarapan pagi dan makanan selingan terhadap kejadian overweight

karbohidrat untuk sarapan pagi sebesar 60-68% dari HASIL

jumlah asupan energi sarapan pagi yang dikategorikan
Sebanyak 6 sekolah yang terpilih terdiri dari 2
tinggi apabila jumlah asupan karbohidrat lebih dari 110,5
sekolah negeri dan 4 sekolah swasta. Seluruh remaja
g (laki-laki) atau 93,5 g (perempuan) sedangkan asupan
dari sekolah yang terpilih diukur berat badan dan
karbohidrat dari makanan selingan dikategorikan tinggi
tinggi badannya untuk mengetahui status gizinya. Hasil
apabila asupan lebih dari 105,6 g (laki-laki) atau 89,4 g
skrining diperoleh prevalensi overweight sebesar 16,8%
(perempuan) (7,16,17). atau sebanyak 432 siswa dari 2573 siswa yang diukur
Asupan energi makanan utama diperoleh dari status gizinya. Subjek penelitian berjumlah 200 siswa
konsumsi makanan utama (makan siang dan makan remaja terdiri dari 100 siswa overweight dan 100 siswa
malam) selain sarapan pagi dan makanan selingan. yang tidak overweight. Selanjutnya, setelah dilakukan
Sarapan pagi harus memenuhi sebanyak 20-25% dari matching maka subjek penelitian terdiri dari 50 kasus dan
kebutuhan kalori sehari sedangkan makanan selingan 50 kontrol dengan jenis kelamin laki-laki serta 50 kasus
menyumbang 20-25% dari total kebutuhan sehari dan 50 kontrol dengan jenis kelamin perempuan.
sehingga kebutuhan energi dari makan utama sebesar Tidak ada perbedaan yang bermakna pada
50-60% dari kebutuhan energi total dalam sehari (7,16). karakteristik subjek penelitian untuk usia ibu dan ayah,
Asupan energi makanan utama dikategorikan tinggi jika tingkat pendidikan ibu dan ayah, status overweight ibu
jumlah asupan energi lebih dari 60% AKG. Lebih lanjut, dan ayah, serta uang saku antara kelompok overweight
variabel luar berupa aktivitas fisik diukur dalam menit dan kelompok tidak overweight. Sementara itu, pekerjaan
dan dinyatakan dalam metabolic energy turnover (METs) ibu ternyata berhubungan bermakna dengan kejadian
kemudian dibedakan menjadi tiga parameter yaitu berat
(jumlah nilai IPAQ > 3000 METs), sedang (jumlah nilai Tabel 1. Karakteristik subjek penelitian
IPAQ = 600-3000 METs), dan ringan (jumlah nilai IPAQ
Tidak
< 600 METs). Overweight
Variabel overweight p
Pengambilan data dibantu oleh tenaga enumerator n % n %
lulusan D3 Jurusan Gizi yang sudah diberikan arahan Usia ibu (tahun)
> 50 5 5 8 8 0,300
dan penjelasan. Persamaan persepsi antara peneliti dan ≤ 50 95 95 92 92
enumerator diketahui melalui uji interrater reliability Usia ayah (tahun)
menggunakan uji statistik Kappa dengan gold standard > 50 25 25 22 22 0,610
adalah peneliti dan hasil ujinya berkisar antara 81,25 ≤ 50 75 75 78 78
Tingkat pendidikan ibu
- 93,75%. Pengolahan data menggunakan program Tidak tinggi 68 68 73 73 0,430
STATA sedangkan data asupan gizi diolah menggunakan Tinggi 32 32 27 27
nutrisurvey. Data dianalisis secara kuantitatif meliputi Tingkat pendidikan ayah
analisis univariat, bivariat, dan multivariat. Analisis Tidak tinggi 55 55 61 61 0,390
Tinggi 45 45 39 39
univariat ini digunakan untuk mengetahui karakteristik Pekerjaan ibu
subjek penelitian, prevalensi overweight, status overweight Bekerja 60 60 43 43 0,016*
subjek, pola konsumsi sarapan pagi, pola konsumsi Tidak bekerja 40 40 57 57
makanan selingan, asupan makan sehari, dan aktivitas Status overweight ibu
Overweight 42 42 35 35 0,310
fisik remaja. Analisis bivariat untuk mengetahui faktor Tidak overweight 58 58 65 65
risiko dari setiap variabel terhadap kejadian overweight. Status overweight ayah
Analisis multivariat untuk mengetahui variabel yang Overweight 44 44 37 37 0,310
Tidak overweight 56 56 63 63
paling besar berpengaruh terhadap kejadian overweight.
Uang saku
Penelitian ini telah memperoleh ethical clearance > rata-rata 28 28 38 38 0,130
dengan nomor KE/FK/22/EC dari Komisi Etik Fakultas ≤ rata-rata 72 72 62 62
Kedokteran Universitas Gadjah Mada. Keterangan: * = bemakna (nilai p < 0,05)

142 • Jurnal Gizi Klinik Indonesia, Vol. 10, No. 3, Januari 2014
 Shelly Festilia Agusanty, dkk: Faktor risiko sarapan pagi dan makanan selingan terhadap kejadian overweight

Tabel 2. Hubungan sarapan pagi dengan kejadian overweight pada remaja

Overweight Tidak overweight OR

Variabel p
n % n % ( 95% CI)
Sarapan pagi
Tidak rutin 89 89 72 72 3,1 0,02*
Rutin 11 11 28 28 (1,40-7,47)
Energi sarapan pagi
Tinggi 9 9 7 7 1,3 0,60
Tidak tinggi 91 91 93 93 (0,41-4,33)
Protein sarapan pagi
Tinggi 5 5 5 5 1,0 1,00
Tidak tinggi 95 95 95 95 (0,22-4,50)
Lemak sarapan pagi
Tinggi 25 25 27 27 0,9 0,75
Tidak tinggi 75 75 72 72 (0,46-1,80)
Karbohidrat sarapan pagi
Tinggi 6 6 7 7 0,8 0,77
Tidak tinggi 94 94 93 93 (0,22-3,07)
Keterangan: * = bemakna (nilai p < 0,05)

overweight (p<0,05) (Tabel 1). Ibu yang bekerja jumlahnya
paling banyak ditemukan pada kelompok overweight
(60%) dibandingkan kelompok tidak overweight (43%).
Salah satu faktor yang dapat dikaitkan antara pekerjaan
ibu dengan kejadian overweight adalah faktor ekonomi.
Status ibu yang juga bekerja selain ayah cenderung
berpengaruh terhadap peningkatan ekonomi keluarga.
Peningkatan ekonomi mempermudah seseorang untuk
memperoleh makanan yang tinggi energi, ketersediaan
pangan yang cukup, dan meningkatkan gaya hidup
sedentari (sedentary lifestyle) (18). Sebagian besar subjek
mendapatkan uang saku dari orang tua dalam jangka
waktu harian. Kelompok overweight maupun kelompok
tidak overweight, sebagian besar mempergunakan uang
saku untuk membeli makanan dan minuman.
Hasil penelitian menunjukkan adanya hubungan
sarapan pagi dengan kejadian overweight (p<0,05).
Remaja yang tidak rutin sarapan pagi mempunyai risiko
menjadi overweight sebesar 3,1 kali (95% CI=1,40-7,47)
dibandingkan remaja yang rutin sarapan pagi. Namun,
energi, protein, lemak, dan karbohidrat dari sarapan pagi
tidak menunjukkan hubungan dengan kejadian overweight
(Tabel 2). Berdasarkan hasil wawancara menggunakan
SQFFQ diperoleh jenis makanan yang sering dikonsumsi
subjek untuk sarapan pagi dan makanan selingan.
Berdasarkan besar frekuensinya, lima peringkat teratas
jenis makanan yang paling sering dikonsumsi untuk
sarapan pagi pada kelompok overweight adalah nasi putih,
mi instan, telur, nasi goreng, dan ayam goreng sedangkan
pada kelompok tidak overweight adalah susu, nasi putih,
roti, mi instan, dan telur.
Tabel 3 menunjukkan gambaran asupan gizi sarapan
pagi pada kelompok overweight dan tidak overweight.
Kelompok remaja yang rutin sarapan pagi, menunjukkan
hubungan bermakna antara asupan energi sarapan pagi
dengan kejadian overweight yaitu remaja dengan asupan
energi sarapan pagi yang tinggi berisiko 6,9 kali (95%
CI=1,3-37,5) menjadi overweight dibandingkan remaja
dengan asupan energi sarapan pagi yang tidak tinggi.
Selain itu, kelompok remaja yang rutin sarapan
pagi juga menunjukkan hubungan bermakna pada asupan
lemak dan asupan karbohidrat dari sarapan pagi dengan
kejadian overweight. Remaja dengan asupan lemak
yang tinggi berisiko 8 kali (95% CI=1,7-38,8) menjadi
overweight dibandingkan remaja dengan asupan lemak
yang tidak tinggi. Sementara itu, remaja dengan asupan
karbohidrat tinggi berisiko 7,5 kali (95% CI=1,1-49,2)
menjadi overweight dibandingkan remaja dengan asupan
karbohidrat yang tidak tinggi.
Hasil penelitian tidak menunjukkan hubungan
yang bermakna antara konsumsi makanan selingan
dengan kejadian overweight (p>0,05). Demikian juga
hubungan antara protein dan lemak makanan selingan
dengan kejadian overweight yang tidak menunjukkan

Jurnal Gizi Klinik Indonesia, Vol. 10, No. 3, Januari 2014 • 143
 Shelly Festilia Agusanty, dkk: Faktor risiko sarapan pagi dan makanan selingan terhadap kejadian overweight

Tabel 3. Asupan zat gizi sarapan pagi pada kelompok overweight dan tidak overweight
berdasarkan rutinitas sarapan pagi remaja

Asupan gizi Overweight Tidak overweight OR

Sarapan pagi p
sarapan pagi n % n % (95% CI)
Tidak rutin Energi tinggi 4 4,5 4 5,6 0,8
1,00
Energi tidak tinggi 85 95,5 68 94,4 (0,2-3,3)
Rutin Energi tinggi 5 45,5 3 10,7 6,9
0,03*
Energi tidak tinggi 6 54,5 25 89,3 (1,3-37,5)
Tidak rutin Protein tinggi 2 2,2 4 5,6 0,4
0,40
Protein tidak tinggi 87 97,8 68 94,4 (0,1-2,1)
Rutin Protein tinggi 3 27,3 1 3,6 10,1
0,06
Protein tidak tinggi 8 72,7 27 96,4 (0,9-111,2)
Tidak rutin Lemak tinggi 17 19,1 20 27,8 0,6
0,26
Lemak tidak tinggi 72 80,9 52 72,2 (0,3-1,3)
Rutin Lemak tinggi 8 72,7 7 25,0 8,0
0,01*
Lemak tidak tinggi 3 27,3 21 75,0 (1,7-38,8)
Tidak rutin KH tinggi 2 2,2 5 6,9 0,3
0,24
KH tidak tinggi 87 97,8 67 93,1 (0,06-1,63)
Rutin KH tinggi 4 36,4 2 7,1 7,5
0,04*
KH tidak tinggi 7 63,6 26 92,9 (1,1-49,2)
Keterangan: KH = karbohidrat; * = bemakna (nilai p < 0,05)

hubungan bermakna. Namun, terdapat hubungan antara
frekuensi makanan selingan, energi makanan selingan,
dan karbohidrat makanan selingan dengan kejadian
overweight (p<0,05) (Tabel 4). Berdasarkan besar
frekuensi jenis makanan selingan yang dikonsumsi
subjek, lima peringkat teratas jenis makanan selingan
yang paling sering dikonsumsi oleh remaja kelompok
overweight adalah mi instan, bakwan, permen, nasi
goreng, dan coklat sedangkan kelompok tidak overweight
adalah bakwan, mi instan, permen, pisang goreng, dan
tahu goreng.
Jumlah remaja yang mengonsumsi makanan
selingan lebih banyak dibandingkan remaja yang tidak
mengonsumsi makanan selingan, baik pada kelompok
overweight maupun tidak overweight dengan persentase
terbesar pada kelompok overweight (94%). Remaja yang
mengonsumsi makanan selingan lebih dari 2 kali dalam
sehari berisiko 1,9 kali (95% CI=1,05-3,50) menjadi
overweight dibandingkan remaja yang mengonsumsi
makanan selingan kurang atau sama dengan 2 kali sehari.
Selain itu, remaja dengan energi makanan selingan yang
tinggi berisiko 2,1 kali (95% CI=1,13-4,02) menjadi
overweight dibandingkan remaja dengan energi makanan
selingan yang tidak tinggi. Demikian juga karbohidrat
makanan selingan yang tinggi berisiko 4,5 kali (95% CI:
1,94-11,50) terhadap kejadian overweight dibandingkan
karbohidrat makanan selingan yang tidak tinggi.
Hasil penelitian menunjukkan asupan energi
makanan utama tidak berhubungan bermakna dengan
kejadian overweight, demikian juga dengan asupan
protein, lemak, dan karbohidrat makanan utama.
Sebaliknya, tingkat aktivitas fisik mempunyai hubungan
yang bermakna dengan kejadian overweight pada remaja
(Tabel 5). Hal ini menunjukkan bahwa remaja overweight
(65%) lebih banyak yang mempunyai aktivitas ringan
dibandingkan remaja yang tidak overweight (43%).
Kurangnya beraktivitas dan asupan makanan yang
tidak seimbang telah diketahui sebagai penyebab utama
meningkatnya berat badan (19). Beberapa penelitian
menunjukkan bahwa perilaku kurang gerak (sedentary
behaviours) seperti menonton televisi dan bermain
komputer berhubungan dengan meningkatnya prevalensi
obesitas (20).
Berdasarkan Tabel 6, setelah dilakukan uji
multivariat maka variabel yang berhubungan bermakna
terhadap kejadian overweight adalah variabel sarapan pagi,
karbohidrat makanan selingan, dan aktivitas fisik. Model
1 untuk mengetahui hubungan variabel sarapan pagi,

144 • Jurnal Gizi Klinik Indonesia, Vol. 10, No. 3, Januari 2014
 Shelly Festilia Agusanty, dkk: Faktor risiko sarapan pagi dan makanan selingan terhadap kejadian overweight

Tabel 4. Hubungan makanan selingan dengan kejadian overweight pada remaja

Overweight Tidak overweight OR

Variabel p
n % n % (95% CI)
Makanan Selingan
Ya 94 94 90 90 1,7 0,300
Tidak 6 6 10 10 (0,55-6,06)
Frekuensi makanan selingan
> 2 kali 62 62 46 46 1,9 0,023*
≤ 2 kali 38 38 54 54 (1,05-3,50)
Energi makanan selingan
Tinggi 44 44 27 27 2,1 0,012*
Tidak tinggi 56 56 73 73 (1,13-4,02)
Protein makanan selingan
Tinggi 11 11 11 11 1,0 1,000
Tidak tinggi 89 89 89 89 (0,37-2,69)
Lemak makanan selingan
Tinggi 59 59 60 60 0,96 0,890
Tidak tinggi 41 41 40 40 (0,52-1,75)
KH makanan selingan
Tinggi 31 31 9 9 4,5 0,000*
Tidak tinggi 69 69 91 91 (1,94-11,50)
Keterangan: KH = karbohidrat; * = bemakna (nilai p<0,05)

Tabel 5. Hubungan asupan zat gizi makanan utama dan aktivitas fisik dengan kejadian
overweight pada remaja

Overweight Tidak overweight OR

Variabel p
n % n % (95% CI)
Energi makan utama
Tinggi 37 37 27 27 1,59 0,130
Tidak tinggi 63 63 73 73 (0,83-3,02)
Protein makan utama
Tinggi 2 2 1 1 2,02 0,560
Tidak tinggi 98 98 99 99 (0,10-22,6)
Lemak makan utama
Tinggi 9 9 6 6 1,5 0,420
Tidak tinggi 91 91 94 94 (0,47-5,5)
KH makan utama
Tinggi 45 45 34 34 1,5 0,110
Tidak tinggi 55 55 66 66 (0,86-2,92)
Aktivitas fisik
2,46
Ringan 65 65 43 43 0,002*
(1,33-4,54)
Sedang 35 35 57 57
Keterangan: * = bemakna (nilai p<0,05)

frekuensi makanan selingan, energi makanan selingan, dan
karbohidrat makanan selingan terhadap kejadian overweight.
Hasil analisis multivariat menunjukkan bahwa sarapan pagi
dan karbohidrat makanan selingan berhubungan bermakna
(p<0,05) dengan kejadian overweight.
Model 2 untuk mengetahui hubungan variabel
sarapan pagi dan karbohidrat makanan selingan
terhadap kejadian overweight. Hasil analisis multivariat
menunjukkan bahwa ada hubungan sarapan pagi dan
karbohidrat makanan selingan (p<0,05) dengan kejadian

Jurnal Gizi Klinik Indonesia, Vol. 10, No. 3, Januari 2014 • 145
 Shelly Festilia Agusanty, dkk: Faktor risiko sarapan pagi dan makanan selingan terhadap kejadian overweight
Tabel 6. Analisis multivariat sarapan pagi dan makanan selingan dengan kejadian
overweight pada remaja
Model Variabel
Model 1 Sarapan pagi
Frekuensi makanan selingan
Energi makanan selingan
Karbohidrat makanan selingan
Model 2 Sarapan pagi
Karbohidrat makanan selingan
Model 3 Sarapan pagi
Karbohidrat makanan selingan
Aktivitas fisik
Keterangan: * nilai p<0,05 ada hubungan variabel dependen dengan variabel independen
overweight. Model 2 ini menunjukkan bahwa remaja
tidak rutin sarapan pagi berisiko 3,6 kali menjadi
overweight dibandingkan remaja yang rutin sarapan
pagi setelah dikontrol dengan karbohidrat dari makanan
selingan. Remaja dengan konsumsi tinggi karbohidrat
dari makanan selingan berisiko 5 kali menjadi overweight
dibandingkan remaja dengan konsumsi tidak tinggi
karbohidrat dari makanan selingan setelah dikontrol
dengan sarapan pagi.
Model 3 untuk mengetahui hubungan variabel
sarapan pagi dan karbohidrat makanan selingan terhadap
kejadian overweight dengan dikontrol variabel aktivitas
fisik. Hasil analisis multivariat menunjukkan bahwa ada
hubungan sarapan pagi, karbohidrat makanan selingan,
dan aktivitas fisik dengan kejadian overweight. Model 3
menunjukkan bahwa remaja yang tidak rutin sarapan pagi
berisiko 4 kali menjadi overweight dibandingkan remaja
yang rutin sarapan pagi dengan dikontrol oleh karbohidrat
dari makanan selingan dan aktivitas fisik. Remaja dengan
konsumsi tinggi karbohidrat dari makanan selingan
berisiko 4,2 kali menjadi overweight dibandingkan
remaja dengan konsumsi tidak tinggi karbohidrat dari
makanan selingan setelah dikontrol dengan sarapan pagi
dan aktivitas fisik.
BAHASAN
Hasil skrining yang dilakukan terhadap enam SMA
di Kota Pontianak diperoleh prevalensi overweight sebesar
16,8%. Prevalensi ini lebih besar apabila dibandingkan
dengan prevalensi overweight pada tahun 2005 untuk
146 • Jurnal Gizi Klinik Indonesia, Vol. 10, No. 3, Januari 2014
Kelompok kasus kontrol
OR p R2
3,60 0,002*
0,098
1,40 0,450
0,70 0,523
5,50 0,002*
3,59 0,002* 0,095
5,05 0,000*
4,03 0,001* 0,124
4,19 0,001*
2,40 0,005*
kelompok usia di atas 15 tahun di provinsi Kalimantan
Barat yaitu sebesar 13%. Berdasarkan data Riskesdas
tahun 2010 menunjukkan bahwa prevalensi overweight
untuk kelompok usia 16-18 tahun sebesar 1,4% dan usia
di atas 18 tahun sebesar 10% (3). Berdasarkan angka
prevalensi tersebut dapat menjadi suatu indikator bahwa
prevalensi overweight telah mengalami peningkatan
khususnya di Kota Pontianak.
Peningkatan prevalensi overweight pada anak-
anak dan remaja telah menjadi masalah utama kesehatan
masyarakat tidak hanya di negara-negara industri (19)
tetapi juga telah menjadi masalah kesehatan masyarakat
di negara-negara berkembang (21). Overweight dan
obesitas pada masa remaja berpengaruh terhadap kejadian
obesitas pada masa dewasa (4). Overweight dan obesitas
pada masa remaja juga berpengaruh terhadap timbulnya
berbagai penyakit degeneratif saat dewasa, yaitu remaja
overweight mempunyai risiko 8,5 kali menderita hipertensi
saat dewasa (22). Remaja overweight juga berisiko 2,4 kali
meningkatnya total kolesterol di atas 240 mg/dl, berisiko 3
kali meningkatnya LDL di atas 160 mg/dl, dan berisiko 8
kali meningkatnya risiko penurunan HDL di bawah 35 mg/
dl di saat usia dewasa. Remaja penderita sindrom metabolik,
sebesar 30-50% adalah remaja overweight (23).
Kegiatan pencegahan dan penanggulangan
overweight yang dapat dilakukan khususnya pada anak
sekolah meliputi promosi, penemuan, dan tatalaksana
kasus yang dalam pelaksanaannya melibatkan anak,
orang tua, guru, komite sekolah, dan stakeholder. Tujuan
pencegahan adalah terjadinya perubahan pola dan
perilaku makan yaitu meningkatkan kebiasaan konsumsi
 Shelly Festilia Agusanty, dkk: Faktor risiko sarapan pagi dan makanan selingan terhadap kejadian overweight
buah dan sayur, mengurangi konsumsi makanan dan
minuman manis, mengurangi konsumsi makanan tinggi
energi dan lemak, mengurangi konsumsi junk food, serta
peningkatan aktivitas fisik, dan mengurangi sedentary
lifestyle (24).
Hasil analisis menunjukkan bahwa ada hubungan
antara sarapan pagi dengan kejadian overweight. Remaja
yang tidak rutin sarapan pagi mempunyai risiko 3,1 kali
untuk menjadi overweight dibandingkan remaja yang
rutin sarapan pagi. Hal ini sesuai dengan penelitian
sebelumnya yang menunjukkan bahwa anak-anak yang
rutin mengonsumsi sarapan pagi di rumah mempunyai
rerata IMT yang lebih rendah dibandingkan anak-anak
yang tidak sarapan pagi (8). Orang yang tidak sarapan
pagi mempunyai IMT lebih tinggi dibandingkan dengan
orang yang sarapan pagi karena orang yang tidak sarapan
pagi cenderung menjadi tidak seimbang pola makannya,
seperti mengonsumsi makan siang dalam jumlah besar
(25).
Beberapa penelitian menunjukkan bahwa anak-
anak dan remaja yang mengonsumsi sarapan pagi
mempunyai jumlah asupan energi yang baik, yang tidak
dapat dikompensasikan apabila tidak sarapan pagi.
Penelitian sebelumnya menunjukkan bahwa anak-anak
dan remaja yang tidak sarapan pagi, jarang mengonsumsi
buah dan sayuran dan cenderung mengonsumsi makanan
jajanan yang tidak sehat saat dalam perjalanan di sekolah
ataupun saat di sekolah (8). Penelitian pada anak sekolah
di Hong Kong juga menyimpulkan bahwa tidak sarapan
pagi berhubungan dengan kejadian overweight dan
obesitas, perilaku makan yang kurang sehat termasuk
meningkatnya frekuensi makan junk food, kurang
mengonsumsi buah dan sayuran serta susu. Orang yang
tidak sarapan pagi juga cenderung untuk tidak makan
siang, jarang mengikuti kegiatan yang berkaitan dengan
aktivitas fisik, dan lebih sering menonton televisi (26).
Rerata asupan energi sarapan pagi kelompok
overweight lebih kecil (208,57±233,53 kkal) dibandingkan
kelompok tidak overweight (299,7±230,67 kkal).
Kelompok tidak overweight cenderung mempunyai
rerata asupan energi, lemak, dan karbohidrat dari sarapan
pagi lebih tinggi dibandingkan kelompok overweight.
Walaupun rerata asupan energi untuk kelompok tidak
overweight lebih besar bila dibandingkan dengan
kelompok overweight, tetapi rerata asupan energi sarapan
pagi pada kelompok overweight maupun kelompok
tidak overweight belum memenuhi kebutuhan energi
sarapan pagi (20-25% dari total asupan energi). Hal
ini menunjukkan bahwa masih kurangnya remaja
mendapatkan asupan energi dari sarapan pagi. Meskipun
beberapa penelitian menunjukkan hasil yang berbeda,
tetapi konsumsi sarapan pagi berhubungan dengan berat
badan yang ideal pada anak dan remaja, bermanfaat
pada fungsi kognitif terutama pada daya ingat, prestasi
akademik, jumlah kehadiran di sekolah, dan psikososial
(27). Anak-anak dan remaja yang tidak sarapan pagi
mengalami penurunan asupan mikro nutrisi dibandingkan
dengan anak-anak dan remaja yang rutin sarapan pagi
dan rendahnya asupan ini tidak dapat digantikan dengan
waktu makan yang lain (28).
Frekuensi mengonsumsi makanan selingan lebih
dari dua kali dalam sehari lebih banyak ditemukan pada
kelompok overweight (62%) dibandingkan kelompok tidak
overweight (46%). Hal ini menunjukkan bahwa remaja
overweight lebih cenderung mengonsumsi makanan
selingan lebih dari dua kali dalam sehari dibandingkan
remaja yang tidak overweight. Faktor penyebab lain
remaja overweight lebih banyak mengonsumsi makanan
selingan lebih dari dua kali dalam sehari adalah jumlah
uang saku yang diterima oleh kelompok overweight lebih
banyak dibandingkan kelompok yang tidak overweight.
Rerata uang saku kelompok overweight sebesar Rp
16.140,- sedangkan kelompok tidak overweight sebesar
Rp 11.950,-. Sebagian besar subjek pada kelompok
overweight dan kelompok tidak overweight menggunakan
uang saku untuk membeli makanan dan minuman
sehingga jika jenis makanan jajanan yang dikonsumsi
sama maka kelompok overweight cenderung lebih banyak
mengonsumsi makanan jajanan dibandingkan kelompok
tidak overweight.
Lebih lanjut, rerata asupan energi makanan
selingan kelompok overweight (440,9±304,8 kkal)
lebih besar dibandingkan kelompok tidak overweight
(400,5±303,3 kkal). Hal ini terkait dengan tingginya
frekuensi konsumsi makanan selingan pada kelompok
overweight dibandingkan kelompok tidak overweight.
Makanan selingan lebih banyak diperoleh dari makanan
jajanan dibandingkan buatan rumah sehingga ada
Jurnal Gizi Klinik Indonesia, Vol. 10, No. 3, Januari 2014 • 147
 Shelly Festilia Agusanty, dkk: Faktor risiko sarapan pagi dan makanan selingan terhadap kejadian overweight
kecenderungan mengonsumsi makanan yang kurang
sehat. Sebagian besar subjek membeli makanan jajanan
di kantin sekolah pada waktu siang hari. Hal ini
menunjukkan bahwa remaja cenderung mengonsumsi
makanan selingan pada saat jam istirahat di sekolahnya.
Menurut hasil penelitian sebelumnya, disimpulkan bahwa
anak yang tidak sarapan pagi berhubungan bermakna
dengan perilaku makan yang tidak sehat, yaitu adanya
kecenderungan bahwa anak yang tidak sarapan akan
membeli makanan dalam perjalanan ke sekolah atau di
kantin sekolah dua kali lebih sering dibandingkan dengan
anak yang sarapan pagi (8).
Sementara itu, hasil penelitian ini juga membuktikan
bahwa frekuensi makanan selingan berhubungan
bermakna dengan kejadian overweight yaitu remaja yang
mengonsumsi makanan selingan lebih dari dua kali dalam
sehari berisiko 1,9 kali menjadi overweight dibandingkan
remaja yang mengonsumsi makanan selingan kurang atau
sama dengan dua kali dalam sehari. Lebih lanjut, energi
makanan selingan mempunyai hubungan bermakna
dengan kejadian overweight. Remaja dengan konsumsi
makanan selingan yang berenergi tinggi akan berisiko
2,1 kali menjadi overweight dibandingkan remaja dengan
konsumsi makanan selingan yang tidak tinggi energi.
Selain itu, remaja dengan konsumsi makanan selingan
yang tinggi karbohidrat akan berisiko 4,5 kali menjadi
overweight dibandingkan remaja dengan konsumsi makanan
selingan yang tidak tinggi karbohidrat. Hal ini menunjukkan
bahwa energi dan karbohidrat makanan selingan mempunyai
pengaruh terhadap kejadian overweight. Berbeda dengan
hasil penelitian sebelumnya yang menyatakan bahwa
prevalensi overweight dan obesitas abdominal menurun
dengan meningkatnya frekuensi makanan selingan dan
meningkatnya persentase energi makanan selingan. Hal ini
dimungkinkan apabila makanan selingan yang dikonsumsi
meningkatkan kualitas makanan hariannya, meningkatkan
asupan buah, sayuran, biji-bijian (whole grain), dan
serat sehingga dapat mempertahankan rasa kenyang dan
menurunkan risiko overweight (7).
Beberapa variabel yang berhubungan dengan kejadian
overweight dan dimasukkan dalam analisis multivariat
yaitu sarapan pagi, frekuensi makanan selingan, energi
makanan selingan, karbohidrat makanan selingan serta
tingkat aktivitas. Hasilnya menunjukkan bahwa variabel
148 • Jurnal Gizi Klinik Indonesia, Vol. 10, No. 3, Januari 2014
yang mempunyai hubungan bermakna terhadap kejadian
overweight adalah sarapan pagi, karbohidrat makanan
selingan, dan aktivitas fisik. Berdasarkan hasil ini dapat
disimpulkan bahwa untuk mengatasi masalah overweight
pada remaja, selain diperlukan perilaku rutin sarapan
pagi, juga harus diimbangi dengan tidak mengonsumsi
makanan selingan yang mengandung tinggi karbohidrat
serta meningkatkan aktivitas fisik.
SIMPULAN DAN SARAN
Prevalensi overweight pada remaja SMA di Kota
Pontianak sebesar 16,8%. Sarapan pagi berhubungan
dengan kejadian overweight pada remaja dan sarapan
pagi yang tidak rutin merupakan faktor risiko terhadap
kejadian overweight pada remaja. Makanan selingan tidak
berhubungan bermakna dengan kejadian overweight pada
remaja. Namun, frekuensi makanan selingan berhubungan
bermakna dengan kejadian overweight pada remaja.
Frekuensi makanan selingan lebih dari dua kali dalam sehari
serta makanan selingan yang tinggi energi dan karbohidrat
merupakan faktor risiko terhadap kejadian overweight.
Aktivitas fisik juga berhubungan bermakna dengan kejadian
overweight dan aktivitas ringan menjadi faktor risiko
terhadap kejadian overweight.
Berdasarkan hasil penelitian ini maka disarankan
bagi remaja untuk sarapan pagi sebelum memulai
aktivitas sehari-hari. Jumlah asupan sarapan pagi
sebaiknya sebesar 20-25% dari AKG dan seimbang nilai
gizinya. Sebaiknya remaja tidak mengonsumsi makanan
selingan yang tinggi energi dan tinggi karbohidrat serta
meningkatkan aktivitas fisik.
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Mouchacca et al. BMC Public Health 2013, 13:828
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RESEARCH ARTICLE Open Access

Associations between psychological stress, eating,

physical activity, sedentary behaviours and body
weight among women: a longitudinal study
Jennifer Mouchacca, Gavin R Abbott and Kylie Ball*

Abstract
Background: There is an increased risk of obesity amongst socioeconomically disadvantaged populations and
emerging evidence suggests that psychological stress may be a key factor in this relationship. This paper reports
the results of cross-sectional and longitudinal analyses of relationships between perceived stress, weight and
weight-related behaviours in a cohort of socioeconomically disadvantaged women.
Methods: This study used baseline and follow-up self-report survey data from the Resilience for Eating and Activity
Despite Inequality study, comprising a cohort of 1382 women aged 18 to 46 years from 80 of the most
socioeconomically disadvantaged neighbourhoods in Victoria, Australia. Women reported their height (baseline
only), weight, sociodemographic characteristics, perceived stress, leisure-time physical activity, sedentary and dietary
behaviours at baseline and three-year follow-up. Linear and multinomial logistic regression were used to examine
cross-sectional and longitudinal associations between stress (predictor) and weight, and weight-related behaviours.
Results: Higher perceived stress in women was associated with a higher BMI, and to increased odds of being
obese in cross-sectional and longitudinal analyses. Cross-sectional and longitudinal associations were found
between stress and both less leisure-time physical activity, and more frequent fast food consumption. Longitudinal
associations were also found between stress and increased television viewing time.
Conclusion: The present study contributes to the literature related to the effects of stress on weight and weight-
related behaviours. The findings suggest that higher stress levels could contribute to obesity risk in women. Further
research is needed to fully understand the mechanisms underlying these associations. However, interventions that
incorporate stress management techniques might help to prevent rising obesity rates among socioeconomically
disadvantaged women.
Keywords: Psychological stress, Eating, Physical activity, Sedentary behaviours, Body weight, Regression analyses

Background socioeconomically disadvantaged or those who are living

Current rates of overweight and obesity in developed
countries present a major threat for population health
[1]. Obesity is a significant risk factor for a range of ad-
verse health conditions, including type 2 diabetes, stroke,
cardiovascular disease and various forms of cancer [2].
Certain population groups are at increased risk of over-
weight and obesity, with higher levels of obesity reported
in women of childbearing age [3,4], those who are
* Correspondence: kylie.ball@deakin.edu.au
Centre for Physical Activity and Nutrition Research, School of Exercise and
Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC
3125, Australia
in socioeconomically disadvantaged neighbourhoods [5-8].
While poor diets and physical inactivity are recognised as
key behaviours implicated in the aetiology of obesity
[9-12], the determinants of the increased risk of obesity
and its determinant behaviours amongst socioeconomi-
cally disadvantaged groups remain poorly understood.
One key factor suggested to be linked to the develop-
ment of obesity and which may be particularly pertinent
among socioeconomically disadvantaged groups is psy-
chological stress. Several studies have reported that
indicators of chronic stress are associated with greater
abdominal adiposity [13,14]. A systematic review of the

© 2013 Mouchacca et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Mouchacca et al. BMC Public Health 2013, 13:828
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literature reported less healthy eating patterns and higher
body weight in individuals in lower social positions who
had higher stress levels, with these patterns more apparent
in women than men [15]. A meta-analysis of longitudinal
studies showed that stress was associated with increasing
adiposity [16]. Furthermore, higher levels of stress in the
family reportedly increases children’s obesity risk [17,18],
and several studies have reported associations between
work stress and obesity risk [19-21]. For example, work
stress has been associated with increased body mass index
(BMI) at follow-up in a group of male and female
employees, with findings also showing increased alcohol
consumption and decreased vegetable consumption in
workers with low job control [22]. However, research on
these relationships has produced inconsistent results
[23,24]. For example, in a group of low-income young
mothers perceived stress was not a significant predictor of
obesity [23].
There are few longitudinal studies that have explored
the relationships between stress, body weight and
weight-related behaviours. Longitudinal studies can
provide insights into the direction and potential nature
of associations among these variables. It is plausible that
obesity is a consequence of stress, for example reflecting
the use of maladaptive coping strategies such as comfort
eating or excessive sedentary behaviours [25]. Previous
studies have reported that chronic stress is associated
with binge or comfort type eating [26], reduced physical
activity levels [27] and increased sedentary behaviours
[28]. Preferences for more palatable, higher fat, energy
dense foods have also been associated with stress
[29,30]. However, prospective research is limited, and
confirmation of the temporal nature of these associa-
tions in longitudinal studies is required. Furthermore,
few studies have explored these relationships in socio-
economically disadvantaged women. As living in a
socioeconomically disadvantaged neighbourhood places
residents at increased risk of both obesity [31] and
psychological stress [32], examining associations
between these factors is particularly pertinent in this
vulnerable population. The aim of this study was to
determine whether perceived stress was associated
cross-sectionally and longitudinally with weight and
weight-related behaviours in a cohort of women living in
socioeconomically disadvantaged neighbourhoods.
Methods
Sample
This study examined baseline (T1) and three-year follow-
up (T2) data collected in 2007–08 and 2010–2011 as part
of the Resilience for Eating and Activity Despite Inequality
(READI) study [33]. This multilevel study followed a
cohort of women aged 18 to 46 years living in socio-
economically disadvantaged neighbourhoods. Ethical
Page 2 of 11
approval for the study was given by the Deakin University
Human Research Ethics Committee, the Victorian Depart-
ment of Education and the Catholic Education Office.
Forty rural and 40 urban neighbourhoods (suburbs)
were randomly selected from the most socioeconomically
disadvantaged third of all areas across Victoria, Australia,
according to the Australian Bureau of Statistics’ (ABS)
Socioeconomic Index for Areas [34]. The sampling frame-
work only included neighbourhoods with more than 1200
inhabitants and within 200 km from Melbourne.
One hundred fifty (150) women from each of the 80
neighbourhoods were randomly selected from the elect-
oral roll. As voting is compulsory for Australian adults,
the electoral roll provides a relatively complete record of
population data in Australian residents aged 18 years
and over. Where there were fewer than 150 women
living in the neighbourhood (n = 3 neighbourhoods), all
those who were eligible were invited to participate. A T1
self-report survey was mailed to an initial sample of
11940 women between August 2007 and January 2008.
The survey assessed women’s physical activity, eating
behaviours, height and weight, and a broad range of
factors thought to influence these behaviours and obesity
risk. A reminder protocol [35] was employed whereby
letters were sent to nonresponders 10 days after the
initial survey package was mailed. A second reminder
letter followed including another copy of the survey after
a further 10 days. The surveys were initially pilot-tested
with a convenience sample of 32 women aged 18 to
46 years and minor modifications were made for clarity
based on the feedback received.
A total of 4934 women returned a completed survey.
Excluding those surveys marked ‘return to sender’
(n = 861) or from women who were otherwise ineligible
(e.g., were deceased, or were incorrectly denoted as
females on the electoral roll); this represented a response
rate of 45%. Data from a further 571 women were
excluded because the women no longer lived in a READI
neighbourhood, nine were excluded because they were
not within the desired age range (18 to 46 years), three
were excluded because the survey was not completed by
the woman it was addressed to, and two subsequently
requested to be withdrawn from the study. This left a
total of 4349 women with T1 data. Comparison of the T1
READI sample with the general population of women
living in the 80 neighbourhoods recorded in the 2006
Census [36,37] showed that a greater proportion of
READI women were Australian born (89% vs. 73%), and
were married or living as married (65% vs. 49%), but a
lower proportion of READI women were in full-time
employment (37% vs. 58%).
Three years following the T1 survey, all participants
who consented to further follow-up in their T1 survey
and remained in a READI neighbourhood (n = 2850)
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were sent a T2 survey, which repeated most of the ques- Measures

tions in the T1 survey. Fifty-one women were excluded Sociodemographic characteristics
as they moved out of a READI neighbourhood. One Participants were asked to provide sociodemographic
thousand nine hundred twelve T2 surveys (n = 1912) information including age, highest level of education
were returned. Data from 483 women were excluded (categorised as ‘low’ - did not complete high school,
due to missing outcome data at T1 or T2, 81 missing ‘medium’ - completed high school/trade certificate/dip-
covariate data and 8 missing stress scores. Some women loma, or ‘high’ - completed tertiary education), marital
had missing data on more than one set of variables, status (categorised as ‘married’ - married/de facto, ‘previ-
leaving an analysis sample of 1382. ously married’ - separated/divorced/widowed, or ‘never
married’), employment status (categorised as ‘working
full-time’, ‘working part-time’ or ‘not currently employed in
Table 1 T1 (baseline) characteristics of the READI sample paid work’), smoking status (categorised as ‘never smoked’,
(n = 1382) ‘used to smoke’, ‘smoke occasionally’, or ‘smoke regularly’),
Mean SD country of birth (categorised as either ‘Australia’ or ‘other’),
Age (years) 35.7 7.7 serious illness, long term injury or disability that prevents
BMI 26.2 5.9 physical activity (categorised as ‘yes’ or ‘no’) and the
number of dependent children (categorised as ‘none’, ‘one’,
Stress 10.0 2.8
‘two’, or ‘three or more’).
n %
Education Weight and BMI
Low – did not complete high school 274 19.8 Participants reported their height at T1 and weight at
Medium – completed high school/trade 687 49.7 T1 and T2. BMI was calculated for each participant at
certificate/diploma T1 and T2 by dividing weight (in kilograms) by height
High – completed tertiary education 421 30.5 (in metres) squared, and categorised as healthy weight
Marital status (18.5–24.9 kg m-2), overweight (25.0–29.9 kg m-2) or obese
Married/defacto relationship 1002 72.5
(BMI 30.0 kg m-2 or more) [2]. Due to the very low number
of women in the underweight category (BMI <18.5 kg m-2)
Separated/divorced/widowed 103 7.5
(n = 126), data for these women were combined with
Never married 277 20.0 those in the healthy weight category.
Number of children (aged up to 18 years
living with woman)
Physical activity and sedentary behaviours
None 515 37.3 Physical activity at T1 and T2 was assessed using the
One 244 17.7 long version of the self-administered International Phys-
Two 380 27.5 ical Activity Questionnaire (IPAQ-L), a well-established
Three or more 243 17.6 survey with demonstrated test-retest reliability and valid-
ity [38]. The IPAQ-L was used to measure leisure-time
Employment status
physical activity (LTPA) and the amount of time women
Working full-time 533 38.6
spent sitting in the last seven days. Women were also
Working part-time 440 31.8 asked to report the amount of time spent sitting watching
Not currently employed (paid work) 409 29.6 television during the past week on both weekdays and
Country of birth weekend days. For each of the T1 and T2 physical activity
Not Australia 107 7.7 and sedentary behaviour measures, tertile splits were used
to categorise women as spending ‘low’, ‘medium’ or ‘high’
Australia 1275 92.3
amount of time engaged in the activity. Tertile splits were
Serious illness, long term injury or disability
that prevents physical activity
used due to highly skewed distributions in the data.
Yes 139 10.1
Food habits
No 1243 89.9 Six variables were used as indicators of food habits.
Smoking status These were selected based on their high energy/low nu-
Never smoked 730 52.8 trient content and they are likely important contributors
Used to smoke 359 26.0 to high-energy intake and obesity risk [39,40]. They in-
Smoke occasionally 114 8.2
clude; potato crisps or salty snack food; chocolate or lol-
lies; cake, doughnuts or sweet biscuits; pies, pasties or
Smoke regularly 179 13.0
sausage rolls; fast foods; pizza; and non-diet soft drink.
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Table 2 Distributions of outcomes within READI sample at T1 and T2

T1 T2
n % n %
BMI category
Healthy weight (18.5–24.9 kg m-2) 722 52.2 645 46.7
Overweight (25.0–29.9 kg m-2) 371 26.8 411 29.7
Obese (BMI 30.0 kg m-2 or more) 289 20.9 326 23.6
LTPA (per week)
Low (≤52 mins) 423 30.6 444 32.1
Medium (53 mins-4 hours) 499 36.1 482 34.9
High (5+ hours) 460 33.3 456 33.0
Sitting time (per week)
Low (≤30 hours) 460 33.3 461 33.4
Medium (31–52 hours) 457 33.1 460 33.3
High (53+ hours) 465 33.6 461 33.4
Television viewing time (per week)
Low (≤13 hours) 459 33.2 460 33.3
Medium (14–21 hours) 474 34.3 487 35.2
High (22+ hours) 449 32.5 435 31.5
Potato crisps or salty snack foods
Low (<once/month) 247 17.9 248 17.9
Medium (1–3 times/month) 555 40.2 575 41.6
High (1+ times/week) 580 42.0 559 40.4
Chocolates or lollies
Low (≤3 times/month) 392 28.4 418 30.2
Medium (once/week) 363 26.3 356 25.8
High (2+ times/week) 627 45.4 608 44.0
Cake, doughnuts and sweet biscuits
Low (≤3 times/month) 622 45.0 662 47.9
Medium (once/week) 357 25.8 348 25.2
High (2+ times/week) 403 29.2 372 26.9
Pies, pastries or sausage rolls
Low (<once/month) 653 47.3 639 46.2
Medium (1–3 times/month) 544 39.4 567 41.0
High (1+ times/week) 185 13.4 176 12.7
Fast foods (e.g. McDonalds, KFC)
Low (<once/month) 629 45.5 615 44.5
Medium (1–3 times/month) 499 36.1 545 39.4
High (1+ times/week) 254 18.4 222 16.1
Pizza
Low (<once/month) 591 42.8 600 43.4
Medium (1–3 times/month) 673 48.7 688 49.8
High (1+ times/week) 118 8.5 94 6.8
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Table 2 Distributions of outcomes within READI sample at T1 and T2 (Continued)
Soft drink (excluding diet soft drink)
Low (don’t drink soft drink)
Medium (<1 serve/day)
High (1+ serves/day)
These variables were assessed using a Food Frequency
Questionnaire (FFQ), which was based on several pre-
viously published and validated Australian question-
naires and assessed food habits during the previous
month [41-43]. There were nine response categories for
each food item ranging from ‘Never or less than once/
month’ to ‘6 or more times a day’. For the soft drink item,
six response options ranged from ‘I don’t drink soft drink’
to ‘10 or more serves/day’. For each of the T1 and T2 food
habits measures, tertile splits based on the distributions
were used to categorise women as having ‘low’, ‘medium’
or ‘high’ intake of each food or drink item.
Perceived stress
Stress was measured using the 4-item Perceived Stress
Scale (PSS), which is used to measure the extent to
which individuals consider situations in their life as
stressful in terms of feeling in control [44]. The PSS has
previously shown adequate reliability and validity among
a sample of males and females participating in a smok-
ing cessation program [45]. The specific questions were:
“During the last month how often have you: (i) felt that
you were unable to control the important things in your
life? (ii) felt confident about your ability to handle your
personal problems? (iii) felt that things were going your
way? (iv) felt difficulties were piling up so high that you
could not overcome them?” Responses were categorised
as ‘never’ (scored 1), ‘almost never’ (2), ‘sometimes’ (3),
‘fairy often’ (4), or ‘very often’ (5). Perceived stress scores
were then calculated by reverse scoring the positively
stated items (ii and iii) and then summing all scale items
(Cronbach’s alpha = 0.78).
Statistical methods
The data were analysed using SPSS Statistics 18.0 (SPSS
Inc., Chicago, IL, USA) and STATA Version 12 (Stata-
Corp, College Station, TX). Multinomial logistic regres-
sion (MLR) was used to examine the cross-sectional
associations between perceived stress, weight-related
behaviours and weight status. Additionally, a linear
regression model was tested to examine the cross-
sectional association between perceived stress and
continuous BMI. Separate models were analysed for each
outcome measure. T1 perceived stress was the predictor.
Longitudinal associations between perceived stress,
weight-related behaviours and weight status outcomes
were examined using MLR. A linear regression model
Page 5 of 11
707 51.2 767 55.5
462 33.4 446 32.3
213 15.4 169 12.2
was used to examine the longitudinal association
between perceived stress and continuous BMI. Separate
longitudinal models were tested for each of the T2
weight and weight-related behaviour outcomes, and
included T1 perceived stress as the predictor. Each
longitudinal model also controlled for the corresponding
T1 weight or behavioural measure, e.g. in the model
with T2 soft drink intake as an outcome, T1 soft drink
intake was included as a covariate. In each MLR analysis,
‘low’ was the reference category for weight-related
outcomes. All analyses controlled for age, education
level, marital status, employment status, smoking status,
the number of dependent children and country of birth,
all assessed at T1. All models were also adjusted for
clustering by neighbourhood. The presence of a serious
illness, long term injury or disability that prevents physical
activity was also controlled for in all regression analyses
predicting physical activity and sedentary behaviour.
Results
T1 sociodemographic characteristics of the sample are
presented in Table 1. The mean age of the sample was
35.71 years (s.d. = 7.7) and the mean BMI was 26.2 (s.d. =
5.9). Most of the women were born in Australia (92.3%)
and had a medium level of education (49.7%).
Table 2 shows the distributions of outcomes within
the sample at T1 and T2. At T1, over half of the women
were in the healthy weight range (52.2%), 26.8% over-
weight and 20.9% obese. Forty-seven percent of women
were in the healthy weight range at T2, 29.7% over-
weight and 23.6% obese. Thirty-one percent of women
engaged in 52 or fewer minutes of LTPA per week
(the cut point for the lowest tertile of LTPA) at T1, and
32% at T2. Thirty-four percent engaged in more than
52 hours of sitting time per week, and 34% watched be-
tween 14–21 hours of television per week at T1. Similarly,
33% engaged in more than 52 hours of sitting time per
week, and 35% watched between 14–21 hours of television
per week at T2. Potato crisps or salty snack food intake of
once or more times per week was reported by 42% of the
sample at T1. However, 42% of the sample reported potato
crisps or salty snack food intake 1–3 times per month at
T2. Most women consumed chocolates or lollies twice or
more times per week at T1 and T2. Fifty-one percent and
56% of women reported that they did not drink soft drink
(excluding diet soft drink) at T1 and T2, respectively.
Most women reported consuming cake, doughnuts and
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Table 3 MLR analyses of cross-sectional associations between stress and behavioural outcomes at T1
T1 outcomesa βb Bc (95% CI) P
BMI 0.13 0.28 (0.17, 0.39) <0.0005
OR (95% CI) P
BMI category
Healthy weight (18.5–24.9 kg m-2)
Overweight (25.0–29.9 kg m-2) 1.06 (1.01,1.11) 0.013
Obese (BMI 30.0 kg m-2 or more) 1.13 (1.08,1.19) <0.0005
LTPA (per week)
Low (≤52 mins)
Medium (53 mins-4 hours) 0.93 (0.88,0.99) 0.014
High (5+ hours) 0.91 (0.86,0.96) <0.0005
Sitting time (per week)
Low (≤30 hours)
Medium (31–52 hours) 1.01 (0.97,1.06) 0.593
High (53+ hours) 0.99 (0.95,1.03) 0.622
Television viewing time (per week)
Low (≤13 hours)
Medium (14–21 hours) 1.02 (0.97,1.07) 0.447
High (22+ hours) 0.99 (0.94,1.03) 0.544
Potato crisps or salty snack foods
Low (<once/month)
Medium (1–3 times/month) 1.02 (0.96,1.08) 0.495
High (1+ times/week) 1.05 (0.98,1.11) 0.145
Chocolates or lollies
Low (≤3 times/month)
Medium (once/week) 0.99 (0.94,1.05) 0.795
High (2+ times/week) 1.04 (0.99,1.09) 0.161
Cake, doughnuts and sweet biscuits
Low (≤3 times/month)
Medium (once/week) 1.00 (0.96,1.04) 0.954
High (2+ times/week) 1.00 (0.96,1.05) 0.890
Pies, pastries or sausage rolls
Low (<once/month)
Medium (1–3 times/month) 0.97 (0.93,1.01) 0.114
High (1+ times/week) 1.00 (0.93,1.07) 0.953
Fast foods (e.g. McDonalds, KFC)
Low (<once/month)
Medium (1–3 times/month) 1.04 (1.00,1.09) 0.069
High (1+ times/week) 1.09 (1.02,1.17) 0.010
Pizza
Low (<once/month)
Medium (1–3 times/month) 0.97 (0.92,1.02) 0.196
High (1+ times/week) 1.01 (0.94,1.08) 0.817
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Table 3 MLR analyses of cross-sectional associations between stress and behavioural outcomes at T1 (Continued)
Soft drink (excluding diet soft drink)
Low (don’t drink soft drink)
Medium (<1 serve/day)
High (1+ serves/day)
a
‘Low’ is the reference category for all outcomes.
Note: All analyses controlled for age, education level, marital status, employment status, smoking status, the number of dependent children, country of birth and
clustering by neighbourhood. Bolded associations were significant.
b
Standardised regression coefficient.
c
Unstandardised regression coefficient with 95% confidence interval.
sweet biscuits, and pizza less than once per week, and
pies, pastries or sausage rolls, and consuming fast foods
(e.g. McDonalds, KFC) less than monthly at T1 and T2.
Table 3 shows the cross-sectional associations between
stress and weight and behavioural outcomes at T1. A posi-
tive association was found between stress levels and
continuous BMI (B = 0.28, CI = 0.17, 0.39, p < 0.0005).
Furthermore, for every increase of one unit on the stress
scale, there was an increase of 6% (CI = 1.01,1.11,
p = 0.013) in the odds of being overweight, and 13%
(CI = 1.08,1.19, p <0.0005) increase in the odds of being
obese. Stress levels were associated with LTPA, such that
higher stress scores were associated with a lower like-
lihood of undertaking medium (OR = 0.93, CI = 0.88,0.99,
p = 0.014) or high (OR = 0.91, CI = 0.86,0.96, p < 0.0005)
levels of LTPA. There were no cross-sectional associations
found between stress and sedentary behaviour measures.
Similarly, few cross-sectional associations between stress
and measures of food habits were found. However, stress
was associated with increased odds of high intakes of fast
foods (OR = 1.09, CI = 1.02,1.17, p = 0.010).
Table 4 shows the longitudinal associations between
stress (T1) and weight and behavioural outcomes (T2).
A positive association was found between stress levels
and BMI (B = 0.085, CI = 0.04-0.13, p < 0.0005). Stress
was not predictive of being in the overweight BMI
category (25.0–29.9 kg m-2), but higher stress levels were
associated with an increase of 11% (CI = 1.00,1.23,
p = 0.043) in the odds of being obese at T2. Longitudinal
associations were also found between stress levels and
the likelihood of engaging in medium (OR = 0.93, CI =
0.88, 0.98, p = 0.004) or high (OR = 0.89, CI = 0.84,0.94,
p <0.0005) amounts of LTPA. Associations were also
found between stress and television viewing, such that
each increase of one unit corresponded to a 7% increase
in the odds of watching medium amounts of television
(CI = 1.01,1.12, p = 0.014). Consistent with cross-sectional
associations, stress and fast food intake were longitudin-
ally associated, such that greater stress scores predicted
increased likelihood of consuming high intake of fast food
(OR = 1.08, CI = 1.02,1.14, p = 0.011), but there were no
other dietary associations.
Page 7 of 11
1.00 (0.95,1.04) 0.930
1.07 (1.00,1.14) 0.053
Discussion
This study examined the associations between stress,
weight and weight-related behaviours in a cohort of
women living in socioeconomically disadvantaged neigh-
bourhoods. The findings of this study are generally con-
sistent with those of similar studies in other populations
regarding the relationships between stress and weight
[15,19]. The present study found that higher stress in
women was associated with increased odds of having a
higher BMI, and of being obese. Cross-sectional and
longitudinal associations were found between stress and
both less leisure-time physical activity, and more
frequent fast food consumption. Longitudinally, stress
was also found to be a predictor of increased television
viewing time.
Consistent with our findings, several studies have
reported associations between stress and BMI [15,19,46].
A meta-analysis of longitudinal studies on stress and adi-
posity also found that stress promotes weight gain [16].
However, a study of adolescents in the United Kingdom
found that there was no association between perceived
stress and increases in weight over five years [24]. Incon-
sistencies in these results may be due to the difficulty in
measuring stress, particularly in different age groups and
populations. In the study with adolescents, the PSS was
used to measure stress. This measure was initially devel-
oped to subjectively measure stress in adults, and ado-
lescents may interpret questions differently. More valid
measures of stress might provide more consistency in
results among different studies. The majority of previous
studies of stress and weight have not assessed associated
weight-related behaviours, and hence shed little insight
into potential mechanisms by which stress may influence
weight change or obesity risk. Existing studies on the
associations between stress and physical activity, for
example, have produced inconsistent results [27,47,48].
However, our findings concur with those of several past
studies showing that stress is associated with engaging
in less physical activity [27,47]. Less engagement in
physical activity due to stress may reflect challenging life
circumstances and difficulty coping, which may take pre-
cedence over self-care and health-promoting behaviours
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Table 4 MLR analyses of longitudinal associations between T1 stress and behavioural outcomes at T2
T2 outcomesa βb Bc (95% CI) P
BMI 0.04 0.09 (0.04, 0.13) <0.0005
OR (95% CI) P
BMI category
Healthy weight (18.5–24.9 kg m-2)
Overweight (25.0–29.9 kg m-2) 1.02 (0.97,1.08) 0.454
Obese (BMI 30.0 kg m-2 or more) 1.11 (1.00,1.23) 0.043
LTPA (per week)
Low (≤52 mins)
Medium (53 mins-4 hours) 0.93 (0.88,0.98) 0.004
High (5+ hours) 0.89 (0.84,0.94) <0.0005
Sitting time (per week)
Low (≤30 hours)
Medium (31–52 hours) 0.96 (0.92,1.00) 0.051
High (53+ hours) 1.02 (0.97,1.08) 0.339
Television viewing time (per week)
Low (≤13 hours)
Medium (14–21 hours) 1.07 (1.01,1.12) 0.014
High (22+ hours) 1.04 (0.98,1.11) 0.146
Potato crisps or salty snack foods
Low (<once/month)
Medium (1–3 times/month) 1.01 (0.95,1.07) 0.745
High (1+ times/week) 1.04 (0.98,1.10) 0.219
Chocolates or lollies
Low (≤3 times/month)
Medium (once/week) 1.01 (0.96,1.07) 0.652
High (2+ times/week) 1.02 (0.97,1.07) 0.453
Cake, doughnuts and sweet biscuits
Low (≤3 times/month)
Medium (once/week) 1.01 (0.96,1.05) 0.787
High (2+ times/week) 1.00 (0.95,1.04) 0.931
Pies, pastries or sausage rolls
Low (<once/month)
Medium (1–3 times/month) 0.98 (0.94,1.02) 0.401
High (1+ times/week) 1.05 (0.98,1.12) 0.154
Fast foods (e.g. McDonalds, KFC)
Low (<once/month)
Medium (1–3 times/month) 1.04 (0.99,1.08) 0.103
High (1+ times/week) 1.08 (1.02,1.14) 0.011
Pizza
Low (<once/month)
Medium (1–3 times/month) 0.98 (0.94,1.03) 0.483
High (1+ times/week) 1.02 (0.94,1.11) 0.628
Mouchacca et al. BMC Public Health 2013, 13:828
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Table 4 MLR analyses of longitudinal associations between T1 stress and behavioural outcomes at T2 (Continued)
Soft drink (excluding diet soft drink)
Low (don’t drink soft drink)
Medium (<1 serve/day)
High (1+ serves/day)
a
‘Low’ is the reference category for all outcomes.
Note: All analyses controlled for age, education level, marital status, employment status, smoking status, the number of dependent children, country of birth and
clustering by neighbourhood. Bolded associations were significant.
b
Standardised regression coefficient.
c
Unstandardised regression coefficient with 95% confidence interval.
like physical activity [48]. Furthermore, despite evidence
of the beneficial effects of physical activity on stress [49],
many individuals may find sedentary activity more re-
warding in the short-term [50].
Evidence of the associations between stress and seden-
tary behaviours are limited. The present study found
that stress was longitudinally associated with moderate
amounts of television viewing. Similarly, past research
has shown that highly stressed parents of ill children
were found to watch more hours of television than
parents of healthy children [46]. Individuals in situations
of high stress are more likely to engage in unhealthy
behaviours that make them feel better [51]. Therefore,
stressed women may seek comfort from television viewing
or use television as a distraction from stressful thoughts.
The present study reported few associations between
stress and measures of food habits. This may be due to
the use of the FFQ in our study, which did not assess
portion size, and hence may not be a sufficiently sensitive
instrument to detect any associations between consump-
tion of larger quantities of such food items and stress.
However, stress was found to predict higher intakes of fast
food consumption. Consistent with our findings, a study
by Bauer et al. [17] used a series of questions to measure
the frequency of fast food consumption in parents and
reported more frequent fast food consumption in parents
with greater work-life stress. It is possible that disadvan-
taged women who are feeling stressed may turn to fast
food as a perceived ‘quick fix’, for instance if they are time
poor; or it could be that the types of foods typically pur-
chased in fast food outlets are perceived as ‘comfort’ or
‘reward’ foods and used to cope with stress [52]. A diary
study assessing daily food choice of 30 food items reported
that higher intake of soft drinks and lollies, particularly
chocolate have been reportedly associated with stress [48],
but this was not found in the present study. These dis-
crepant findings may be attributable to the different food
intake measures used, with a diary study potentially cap-
turing daily variances in consumption more readily than
the FFQ used in our study.
This study had a number of strengths. These include
analyses of a large sample from a population of women
living in socioeconomically disadvantaged neighbourhoods
Page 9 of 11
0.98 (0.93,1.03) 0.378
1.04 (0.95,1.15) 0.398
and who are at high risk of weight gain. The large sample
size also allowed control for a range of key covariates. Fur-
thermore, this study is one of few longitudinal studies
assessing the relationships between stress, weight and
weight-related behaviours. Limitations of this study in-
clude the reliance on self-report data, although established
and validated measures were used where possible (e.g., the
IPAQ-L to measure physical activity). Height and weight
were self-reported which may have led to an underesti-
mate of prevalence of overweight and obesity. This may
have resulted in misestimation of the strength of associa-
tions between stress and overweight and obesity. However,
recent evidence suggests substantial agreement between
self-report and measured height and weight among Aus-
tralian women [53]. Food habits were assessed with only a
selected subset of FFQ items, and while these were based
on previously validated scales, the validity of this subset of
questions alone is not established. There was a modest re-
sponse rate to the survey, and considerable loss to follow-
up. For example, longitudinal analyses in this study were
based on a sample of which approximately 10% were
originally sampled. Since we have no information on
weight status or stress from non-respondents to the initial
mailout, we cannot conclude how this bias may affect
results. However, such response and attrition are not atyp-
ical for this population [54,55]. It should also be acknowl-
edged that associations between stress and weight could
operate in the reverse direction to that tested in the
present study. That is, weight gain and obesity may lead to
increased stress, for instance due to weight-related stig-
matization or poor physical or mental health associated
with obesity. Consistent with this hypothesis, several stud-
ies have shown an association between obesity and future
symptoms of depression [56-58]. This remains a question
for future research.
Acknowledging the study’s limitations, and the need
for further confirmation of the mechanisms underlying
the associations observed here, the findings from this
study have important implications for public health
practice, suggesting a potential key role for psychological
stress in weight and weight-related behaviours. Public
health interventions might benefit from the inclusion of
stress management in weight loss interventions to address
Mouchacca et al. BMC Public Health 2013, 13:828
http://www.biomedcentral.com/1471-2458/13/828
psychological health and maximise individuals’ weight loss
and weight maintenance attempts. Particularly, the role of
physical activity in reducing stress (and weight) could be
emphasised in specifically targeted programs.
Conclusion
In conclusion, the present study demonstrated some cross-
sectional and longitudinal associations between perceived
psychological stress and BMI, as well as leisure-time phys-
ical activity, sedentary behaviour and fast food consump-
tion. Developing intervention strategies to improve coping
skills during situations of stress might assist women in so-
cioeconomically disadvantaged neighbourhoods to manage
their weight more effectively.
Abbreviations
READI: Resilience for eating and activity despite inequality;
SIFA: Socioeconomic index for areas; PSS: Perceived stress scale; FFQ: Food
frequency questionnaire; IPAQ: International physical activity questionnaire;
LTPA: Leisure-time physical activity; MLR: Multinomial logistic regression.
Competing interests
The authors declared that they have no competing interests.
Authors’ contributions
JM carried out background research and drafted the manuscript. GA and KB
assisted JM in performing statistical analysis and helped draft the manuscript.
KB conceived the idea for and implemented the READI study, and
developed the measures and methods. All authors read and approved the
final manuscript.
Acknowledgements
The READI study was supported by an Australian National Health and
Medical Research Council Strategic Award (ID 374241) and a Deakin
University Faculty of Health, Medicine, Nursing and Behavioural Sciences
Research Development Grant. The authors gratefully acknowledge the
contributions of Project Manager Michelle Jackson, field staff, and the study
participants. KB is supported by a NHMRC Senior Research Fellowship, ID
479513.
Received: 7 November 2012 Accepted: 5 September 2013
Published: 11 September 2013
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 Public Health Perspectives Journal 5 (1) 2020 9 - 15

Public Health Perspectives Journal

http://journal.unnes.ac.id/sju/index.php/phpj

Obesity Determinants of Teenagers in Rural Areas

Anidaul Fajriyah, Oktia Woro Kasmini Handayani, Widya Hary Cahyati

Universitas Negeri Semarang, Indonesia

Article Info Abstract

______________
ArticleHistory: Obesity is excessive or abnormal fat deposits in adipose tissue, which will
Accepted 21 Oktober improve health. In 2015, at the age of 15 years, obesity was found to be 28.97%,
2019 and in Semarang District, it was found 54.56%. In 2017 obesity increased by ≥15
Approved 08 years, decreased by 6.04%. Whereas in Semarang Regency it was 6.68%. The
February 2020 percentage of the number that has increased, but the number of the number that
Published 20 April has increased from the previous year. The aim of the study was to analyze the
2020 determinants of obesity in teenagers in rural areas. This study uses a case control
design. The population consists of all high school/MA students in Semarang
Regency. The sample consists of 35 obese and 35 non-obese teenagers, with the
Purposive Sampling technique. The instruments used were Semi-Quantitative
Keywords: Food Frequency Questionnaire (SK-FFQ) and Physical Activity Questionnaire
Determinant, for Adolescent (PAQ-A). Data analysis using Chi-square test and logistic
Obesity, Rural Areas regression test. The analysis showed that there was a relationship between energy
___________ intake (p=0,000), protein intake (p=0.002), fat intake (p=0.008), carbohydrate
intake (p=0.002), snack consumption (p=0.031), and physical activity (p=0.02)
with obesity in teenagers in rural areas. The most dominant risk factors for
obesity are energy intake, physical activity, and protein intake. Physical activity
that can increase the risk of obesity in teenagers is decided to improve teenager
welfare.

© 2020 Universitas Negeri Semarang


Correspondence Address: p-ISSN 2528-5998
Kampus Pascasarjana UNNES Jl. Kelud Utara 3 Sampangan
Semarang, Indonesia e-ISSN 2540-7945
E-mail: anidaul17@gmail.com
 Anidaul Fajriyah, Oktia Woro Kasmini Handayani, Widya Hary Cahyati
Public Health Perspectives Journal 5 (1) 2020 9 - 15
INTRODUCTION
Obesity is a condition where there is
excessive or abnormal fat deposits in adipose
tissue, which will interfere with health.
Worldwide, more than 2.1 billion people are
overweight or obese (Ulilalbab, Anggraeni, &
Lestari, 2017).
Based on the RISKESDAS results, at the
age of ≥15 years, the proportion of obesity
experienced a significant increase, namely from
18.8% in 2007, to 26.6% in 2013, and then 31%
for 2018. In 2013 the RISKESDAS results stated
that obese teenagers were 2.5% in children aged
13-15 years, and 1.6% in teenagers aged 16-18
years. When viewed from 2007 and 2013, the
prevalence of obesity has increased, namely 1.4%
to 7.3% (Health Research and Development
Agency, 2018).
In Central Java, in 2015 found the
percentage of obesity at the age of ≥15 years in
Central Java as much as 28.97% of the
measurements of obesity carried out. In Semarang
Regency, the percentage of obesity is higher than
the percentage in Central Java, which reached
54.56%. Then in 2017 the percentage of obesity at
the age of> 15 years experienced a decline to
6.04%. For the Semarang Regency area as much
as 6.68%. Although in terms of percentage it has
decreased, but in terms of the number of cases
found it has increased from the previous year.
Obesity can occur due to several factors
that affect. Diet and physical activity are direct
determinants of obesity. Diet is a type of food, the
amount of food consumed, and the frequency of
consumption of foods containing energy
substances, protein, fat, carbohydrates. According
to the Ministry of Health, observations arise as a
result of high intake of food/drinks which contain
energy nutrients, saturated fats, added sugar and
salt. In addition, the lack of consumption of
vegetables, fruits, and whole cereals. Apart from
food intake factors, there are also physical activity
factors that are lacking (Ministry of Health
Republic of Indonesia, 2014).
Food intake is a factor that can lead to
obesity. Snack is one of the types of food
consumed. Street food consumption is the most
influential factor in teenager obesity (Suraya,
10
2018). Snack food can be in the form of western
fast food and local snacks. According to Pramono
& Sulchan (2014), found that there is a significant
relationship between the contribution of western
fast food, local snacks to obesity in teenagers
(Pramono & Sulchan, 2014). The same thing was
also found by Mardhiati & Setiawan. Obese
teenagers have the habit of consuming fast food
and snacks in school more than teenagers who are
not obese (Mardhiati & Setiawan, 2017). In
addition, in the United Arab Emirates it was
found that fast food has a significant relationship
with obesity in women. In addition, the risk of
obesity is higher in teenager boys due to eating
fast food at home compared to teenager girls (bin
Zaal, Musaiger, & Souza, 2009).
Apart from several direct causative factors,
environmental and genetic factors also play a role
in the occurrence of obesity in a person (Ulilalbab
et al., 2017). The neighborhood will determine
the availability of available food. In 2016, food
expenditure of the population in rural areas
(59.71%) was much higher than the population in
urban areas (47.16%). This situation indicates that
the level of welfare and food security in rural
areas is lower than in urban areas. In addition, the
urban population expenditure tends to be food
and beverages and meat. While for rural
residents, food expenditure will be higher in the
group of grains, vegetables and fish (Ministry of
Health, Republic of Indonesia, 2018).
The home environment has an influence on
the incidence of obesity through the availability of
food and physical activity. The more poor food
intake and physical activity, the higher the risk of
obesity. Children in rural areas report that they
participate in training/sports five or more times
compared to children in urban areas (Liu et al.,
2012).
The emergence of obesity in a person will
have a worrying impact in terms of health will
arise. Diseases arising from obesity include
hypertension and diabetes mellitus. Along with
the increasing prevalence of obesity, the
prevalence of type 2 diabetes has also increased
sharply (Adriani & Wijatmadi, 2016). In addition,
teenagers who are obese tend to experience low
self-esteem, poor self-esteem, experience
difficulties while studying and in school which
 Anidaul Fajriyah, Oktia Woro Kasmini Handayani, Widya Hary Cahyati
Public Health Perspectives Journal 5 (1) 2020 9 - 15

can then lead to depression (Pujiastuti, Fadlyana,
& Garna, 2013).
Some of the effects that may arise due to
obesity, it is necessary to take precautionary
measures by looking at the factors that influence
it. From several studies, factors that influence
obesity include diet, consumption of snacks, and
physical activity. In addition, variable residence
can affect obesity.
The purpose of this study is to analyze the
determinants of obesity in teenagers in rural areas.
METHOD
This research is a quantitative study using
case control design. The population in this study
were all teenagers of state high school/MA
students in Semarang Regency selected using the
Purposive Sampling technique. The minimum
number of samples was 35 obese teenagers (case
group) and 35 non-obese teenagers (control
group). Inclusion criteria for obese teenager
groups were students with BMI measurement
results ≥27 kg/m2. Criteria for non-obese teenager
groups are students with a BMI of 18.5–24.9
kg/m2, coming from the same school and the
same sex as the obese teenager group. Exclusion
criteria were students who were not willing to be
respondents of the study and were not present
when collecting data. Data analysis used Chi-
square test, and logistic regression test. Data
processing using the SPSS v.20 application.

RESULTS AND DISCUSSION

Table1. Bivariate analysis of energy, protein, fat, and carbohydrate intake by group (n=70)
Sufficiency level IK 95%
Nutrients Group p-value* OR
Normal Over Min Max
Energy Control 31 (88.6%) 4 (11.4%) 0.000 13.115 3.77 45.629
Case 13 (37.1%) 22 (62.(%)
Protein Control 25 (71.4%) 10 (28.6%) 0.002 5.455 1.96 15.176
Case 11 (31.4%) 24 (68.6%)
Fat Control 25 (71.4%) 10 (28.6%) 0.008 4.231 1.55 11.546
Case 13 (37.1%) 22 (62.9%)
Carbohydrate Control 26 (74.3%) 9 (25.7%) 0.002 5.537 1.976 15.516
Case 12 (34.3%) 23 (65.7%)
*Chi-square

Nutrient intake in teenagers in rural areas
has been shown in table 1. Starting from the intake
of energy, protein, fat, and carbohydrates shows
that in teenagers who are not obese tend to have a
normal nutrient intake. Conversely, teenagers who
are obese tend to have excessive nutrient intake.
The results of the analysis using the Chi-square test
between energy intake, protein, fat, and
carbohydrates with obesity get p<0.05 so that it
can be concluded that there is a relationship
between energy intake, protein, fat, and
carbohydrate with obesity in teenagers.
Rural areas are rural areas where farmers
still grow their food sources. According to the
observations of researchers, the rural environment
for research there are still many farmers who grow
rice. In addition, there are still many vegetables
found in people's gardens or yards, so that daily
food needs can be picked directly from the
garden/yard. Most rural residents consume food
sources of vegetable protein such as tempeh, tofu,
beans.
The bivariate analysis between energy
intake and obesity scores p=0,000. Therefore, it
can be concluded that there is a relationship
between energy intake and obesity in teenagers in
rural areas. The results of this study are in
accordance with several previous studies. The
results of previous studies found that energy intake
was significantly associated with obesity in
teenagers (p<0.05) (Kurdanti et al., 2015; Loliana
& Nadhiroh, 2015; Nugroho, Hanim, & Dewi,
2018).
The results of bivariate analysis between
protein intake and obesity obtained p=0.002. It
can be concluded that there is a significant

11
 Anidaul Fajriyah, Oktia Woro Kasmini Handayani, Widya Hary Cahyati
Public Health Perspectives Journal 5 (1) 2020 9 - 15
relationship between protein intake and obesity in
teenagers in rural areas. This finding is consistent
with research conducted by Restuastuti (2016),
namely that there is a relationship between protein
intake and obesity in teenagers in Pekanbaru
(Restuastuti, Jihadi, & Ernalia, 2016).
In addition, in this study it was found that the
majority of teenagers who had excess protein
intake were teenagers who were obese, which was
as much as 68.6%. These findings are consistent
with Loliana's study which found that teenagers
with excessive protein intake were found mostly in
obese teenagers (Loliana & Nadhiroh, 2015).
Fat intake has a significant relationship with
obesity in teenagers in rural areas with a p value of
0.002. These findings are identical to the results of
several previous studies. Loliana (2015) found that
fat intake had a significant relationship with the
incidence of obesity in teenagers with a p value
<0.05 (Loliana & Nadhiroh, 2015).
In addition, in this study it was found that
as many as 62.9% of teenagers who have excess fat
intake are teenagers who are obese. Like the
findings by Kurdanti (2015), who found that
56.9% of obese teenagers have excess fat intake
(Kurdanti et al., 2015). According to some of these
Table 2. Bivariate analysis of snacks consumption and physical activity by group (n=70)
Sufficiency level
Factors Group
Low
Snacks consumption Case 23 (65.7%)
Control 13 (37.1%)
Physical activity Case 19 (54.3%)
Control 29 (82.9%)
*Chi-square
Teenagers who are not obese tend to have
low consumption of snacks. Conversely, obese
teenagers have high levels of snacks consumption.
However, it has been found that the majority of
teenagers who are neither obese nor who are
obese have low physical activity (see table 2).
Analysis using the Chi-square test showed
that there was a significant relationship between
consumption of snacks with obesity in teenagers in
rural areas with a value of p=0.031. The results of
this study are in accordance with the findings of
Pramono (2014) in his research, namely that the
findings, it can be concluded that fat intake has a
relationship to obesity in teenagers in rural areas,
both animal protein, and vegetable protein.
Carbohydrate intake is a macro nutrient that
can affect obesity (Indonesian Ministry of Health,
2014). As many as 65.7% of teenagers with excess
carbohydrate intake are teenagers who are obese.
The findings of this study are consistent with
research conducted by Kurdanti (2015), where as
many as 66.7% of teenagers with excess
carbohydrate intake are found in teenagers with
obesity (Kurdanti et al., 2015).
The results found that there was a
relationship between carbohydrate intake and
obesity in teenagers in rural areas with a p-value of
0.002. This finding is in line with previous
research findings, that carbohydrate intake has a
significant relationship with obesity in teenagers
with a p value <0.05 (Kurdanti et al., 2015;
Loliana & Nadhiroh, 2015; Restuastuti et al.,
2016).
Based on the results of the analysis that has
been done, it can be concluded that a diet
consisting of energy, protein, fat, and carbohydrate
intake has a significant relationship with obesity in
teenagers in rural areas.
IK 95%
p-value* OR
High Min Max
12 (34.3%) 0.031 3.244 1.219 8.629
22 (62.9%)
16 (45.7%) 0.020 4.07 1.352 12.255
6 (17.1%)
contribution of snacks has a relationship with
obesity in teenagers (Pramono & Sulchan, 2014).
In addition, previous research found that the
frequency of fast food consumption, total fast food
energy intake, fast food consumption habits were
associated with obesity in teenagers (Kurdanti et
al., 2015; Oktaviani, Saraswati, & Rahfiludin,
2012; Rafiony, Purba, & Pramantara, 2015).
High consumption of snacks was mostly
found in the group of teenagers who were obese.
This finding was in accordance with the results of
previous studies, that as many as 60% of teenagers
12
 Anidaul Fajriyah, Oktia Woro Kasmini Handayani, Widya Hary Cahyati
Public Health Perspectives Journal 5 (1) 2020 9 - 15
with contribution of snacks energy >300 kcal/day
were teenagers who are obese (Pramono &
Sulchan, 2014).
Based on the results of bivariate analysis,
physical activity has a significant relationship with
obesity in teenagers (p-value=0.020). The results of
these studies were identical to the findings in
previous studies, that physical activity has a
relationship with obesity in teenagers (Kurdanti et
al., 2015; Musralianti, Rattu, & Kaunang, 2016;
Pramono & Sulchan, 2014). Not only that, in this
study it was found that most teenagers who have
low physical activity were teenagers with obesity.
In addition, Ruslie & Darmadi (2012) also found
that less physical activity has a relationship with
more weight in teenagers (Ruslie & Darmadi,
2012).
This study found that the majority of
teenagers who have low physical activity were
teenagers who were obese, which was as much as
Table 3. Multivariate analysis of obesity risk factors in teenagers in rural areas (n=70)
Coefficient S.E. Wald
Protein 2.696 0.868 9.657
Energy 1.378 0.709 3.774
Constant 2.493 0.872 8.176
Physical
-3.250 0.917 12.551
Activity
Table 3 shows the results of the logistic
regression test for risk factors for obesity in
teenagers. The results of multivariate analysis
showed that risk factors for obesity in teenagers in
rural areas include energy intake, protein intake
and physical activity. In rural areas, the effect of
energy intake on obesity in teenagers was equal to
14,827 times. Another influential risk factor was
protein intake, which was 3,965 times. Then the
last risk factor was physical activity with a risk of
12,101 times. According to the results of this
analysis, it can be concluded based on a large
order of risk figures, that obesity in teenagers was
most influenced by energy intake, physical
activity, then protein intake.
Energy intake is the most influential risk
factor for obesity in teenagers with OR
values=14.827 CI (95%)=2.707–81.214. These
results can be concluded that the teenagers with
13
82.9%. This finding was in line with Restuastuti
(2016), that as many as 81.8% of teenagers who
were lacking in sports were teenagers who were
obese (Restuastuti et al., 2016). Danari's findings
(2013) found something similar, that as many as
85.3% of obese children had mild physical activity.
The remaining 14.7% were non-obese children
with mild physical activity (Danari, Mayulu, &
Onibala, 2013).
According to the results of the analysis that
has been done, it can be concluded that the
consumption of snacks and physical activity have
a significant relationship with obesity in teenagers
in rural areas. In addition, special attention was
needed to teenagers related to physical activities
undertaken. Most teenagers have low physical
activity, so the efforts were needed in order to
increase physical activity and reduce sedentary
lifestyle in teenagers.
CI (95%)
df p-value OR
Min Max
1 0.002 14.827 2.707 81.214
1 0.052 3.965 0.988 15.916
1 0.004 12.101 2.191 66.841
1 0.000 0.039
excessive energy intake have a risk of 14,827 times
greater to be obese compared to the teenagers who
have normal energy intake. This finding was
identical with previous research, that total energy
intake was the most dominant factor towards
obesity in teenagers in Pontianak (Rafiony et al.,
2015). The results of this study were in accordance
with a survey conducted by the Ministry of Health,
that rural populations tend to consume whole
grains (Ministry of Health, Republic of Indonesia
2018).
Physical activity is a risk factor that affects
obesity in teenagers in rural areas with an
OR=12,101 CI (95%)=2,191–66,841. Teenagers
who have low physical activity are 12,101 times as
likely to be obese. This study was the same as
previous studies, that according to path analysis
physical activity has a direct influence on the
 Anidaul Fajriyah, Oktia Woro Kasmini Handayani, Widya Hary Cahyati
Public Health Perspectives Journal 5 (1) 2020 9 - 15
incidence of obesity (Abudu, Handayani, &
Yuniastuti, 2019).
Low physical activity can cause low energy
output, which is excess residual energy in the body
and then stored in the form of fat, which will
increase the risk of obesity (Adriani & Wijatmadi,
2016; Ulilalbab et al., 2017). Pramono (2014) in
his research found that physical activity has an
effect of 5.128 times on obesity in teenagers.
Physical activities that were often carried out by
teenagers include playing mobile phones, playing
games, sitting in the cafeteria, sleeping while
reading comics/novels, from some of the physical
activities were sedentary activities (Pramono &
Sulchan, 2014). Teenagers who have low physical
activity and high sedentary lifestyle are more at
risk for being overweight or obese (Almughamisi,
George, & Harding, 2018; Aryeetey et al., 2017;
Kurdaningsih, Sudargo, & Lusmilasari, 2016).
However, the results of the study showed
that most teenagers who experience or do not
experience obesity have low physical activity. This
finding slightly illustrates the similarity with a
survey conducted by the government. According
to RISKESDAS which found that as many as
33.5% of Indonesia's population aged >10 years
have less physical activity. This figure has
experienced a significant increase since 2013, from
26.1% to 33.5% in 2018 (Health Research and
Development Agency, 2018). Looking at the data,
special attention needs to be paid to aspects of
physical activity.
Other risk factors that influence obesity in
teenagers are protein intake, OR=3,965 CI
(95%)=0.988–15,916. Excess protein intake in
teenagers is 3,965 times greater risk of obesity
compared to normal protein intake. The results of
this study are identical to the research by Loliana
found that teenagers with excessive protein intake
are found in teenagers with obesity (Loliana &
Nadhiroh, 2015). Protein intake in rural areas is
mostly obtained from consumption of vegetable
protein, such as tempeh, tofu, and beans.
Consumption of animal protein food sources is not
often done by teenagers in rural areas. Even so,
protein food sources have been replaced with
vegetable protein sources.
14
CONCLUSION
Risk factors for obesity in teenagers in rural
areas based on the order of the results of large
statistical effects include energy intake, physical
activity, then protein intake. Therefore, prevention
or appropriate measures are needed so that obesity
does not occur in teenagers and continues into
adulthood. One of the efforts that can be done is to
provide information about balanced nutrition.
Counseling can involve both the school and
parents, so that healthy and nutritionally balanced
food supervision can be achieved. In addition,
given the low physical activity in teenagers who
are still low, special attention needs to be given.
The school can certainly create programs to
increase physical activity by students. In addition,
when at home need supervision from parents so
that teenagers are not lazy about doing physical
activity.
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(2019) 19:612
Vuurendkk. Kesehatan Masyarakat BMC https://
doi.org/10.1186/s12889-019-6832-z

ARTIKEL PENELITIAN Akses terbuka

Asosiasi antara kelebihan berat badan

dan masalah kesehatan mental di
kalangan remaja, dan peran mediasi
viktimisasi
Cornelia Leontine van Vuuren1,4*, Gusta G. Wachter1, René Veenstra2, Judith JM Rijnhart3, Marcel F. van der Wal1, Mai
JM Chinapaw4dan Vincent Busch1

Abstrak
Latar belakang:Bukti belum konklusif tentang apakah kelebihan berat badan remaja dikaitkan dengan kesehatan mental, mungkin
disebabkan oleh hubungan tidak langsung, namun belum teruji. Oleh karena itu, tujuan dari penelitian ini adalah untuk menguji hubungan
antara kelebihan berat badan atau obesitas dan masalah kesehatan mental di kalangan remaja, dan untuk menentukan apakah viktimisasi
memainkan peran mediasi dalam asosiasi ini.

Metode:Data yang dilaporkan sendiri tentang kesehatan mental dan viktimisasi dan data Indeks Massa Tubuh yang diukur secara
objektif digunakan, menggunakan tiga kohort (2010-2011 hingga 2012-2013) dan interval antara gelombang pengukuran dua tahun
kemudian. Kami melakukan analisis mediasi multi-level dengan struktur dua tingkat untuk menggabungkan pengelompokan
pengukuran dalam individu. Populasi penelitian terdiri dari 13.740 siswa sekolah menengah, berusia 13–14 tahun pada saat
pengukuran pertama, di Amsterdam, Belanda.

Hasil:Dibandingkan dengan rekan-rekan mereka dengan berat badan normal, remaja dengan kelebihan berat badan atau obesitas
melaporkan masalah psikososial dan pikiran untuk bunuh diri lebih sering. Korban adalah mediator yang signifikan dalam
hubungan antara kelebihan berat badan, dan masalah psikososial (efek tidak langsung OR: 2.3; 95% CI 1.5, 3.7 dan efek langsung
OR: 1.4; 95% CI 1.2, 1.7) atau pikiran untuk bunuh diri (efek tidak langsung OR: 2.1; 95% CI 1.4, 3.2 dan efek langsung ATAU: 1.3;
95% CI 1.1, 1.5). Hubungan antara obesitas, dan masalah psikososial (tidak langsung OR: 6.2; 95% CI 2.8, 14,7 dan efek langsung
OR: 1.4; 95% CI 1.0, 2.0), atau pikiran untuk bunuh diri (tidak langsung OR: 4.5; 95% CI 2.3, 9.1 dan efek langsung OR: 1.5; 95% CI
1.1, 2.0) bahkan lebih kuat.
Kesimpulan:Kegemukan dan obesitas secara signifikan terkait dengan masalah kesehatan mental pada remaja, dan viktimisasi
memainkan peran mediasi dalam hubungan ini. Korban dan kesehatan mental harus diintegrasikan ke dalam program
pencegahan yang membahas perkembangan berat badan yang sehat. Selain itu, kelebihan berat badan harus diberikan
perhatian lebih dalam program untuk mencegah viktimisasi dan meningkatkan kesehatan mental remaja.

Kata kunci:Kegemukan, Obesitas, Masalah kesehatan mental, Korban intimidasi, Pemuda

* Korespondensi:lvvuuren@ggd.amsterdam.nl
1Departemen Epidemiologi, Promosi Kesehatan dan Inovasi Perawatan
Kesehatan, Layanan Kesehatan Masyarakat (GGD) Amsterdam, Nieuwe
Achtergracht 100, 1018 WT Amsterdam, Belanda
4Departemen Kesehatan Masyarakat dan Kerja, Institut Penelitian Kesehatan

Masyarakat Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, PO BOX

7057, 1007 MB, Amsterdam, Belanda
Daftar lengkap informasi penulis tersedia di akhir artikel

© Penulis. 2019Akses terbukaArtikel ini didistribusikan di bawah ketentuan Lisensi Internasional Creative Commons Attribution 4.0 (
http://creativecommons.org/licenses/by/4.0/), yang mengizinkan penggunaan, distribusi, dan reproduksi tanpa batas dalam media
apa pun, asalkan Anda memberikan kredit yang sesuai kepada penulis asli dan sumbernya, memberikan tautan ke lisensi Creative
Commons, dan menunjukkan jika ada perubahan. Pengabaian Dedikasi Domain Publik Creative Commons (http://
creativecommons.org/publicdomain/zero/1.0/) berlaku untuk data yang disediakan dalam artikel ini, kecuali dinyatakan lain.
Vuurendkk. Kesehatan Masyarakat BMC (2019) 19:612
Latar belakang
Kelebihan berat badan remaja adalah fenomena yang tersebar
luas [1,2]. Pada tahun 2016, secara global sekitar 17% remaja
mengalami kelebihan berat badan, termasuk obesitas.3]. Di
Belanda, sekitar 15% anak berusia 14 dan 16 tahun mengalami
kelebihan berat badan.4] dan di Amsterdam prevalensinya sekitar
20% [5–7]. Kelebihan berat badan remaja, selain mempengaruhi
kesehatan fisik, dapat berdampak negatif terhadap kesehatan
mental. Namun, bukti belum meyakinkan apakah kelebihan berat
badan remaja dikaitkan dengan masalah psikososial dan pikiran
untuk bunuh diri. Beberapa penelitian telah menemukan
hubungan dengan masalah kesehatan mental, seperti depresi, ide
dan upaya bunuh diri, kecemasan, masalah perilaku, harga diri
rendah dan citra diri yang buruk.8–14], sedangkan penelitian lain
tidak menemukan bukti asosiasi tersebut [15–18].
Temuan yang tidak konsisten ini mungkin disebabkan oleh
hubungan tidak langsung antara kelebihan berat badan dan
obesitas dan masalah kesehatan mental yang belum diuji [19].
Mediator yang mungkin adalah viktimisasi [20–22]. Kelebihan
berat badan tidak sejalan dengan norma dan cita-cita budaya
Barat yang berlaku tentang penampilan fisik.23]. Remaja
dengan kelebihan berat badan menonjol secara negatif dan
sering mengembangkan citra diri yang buruk, yang
meningkatkan risiko diintimidasi oleh teman sebaya [24–32].
Meskipun beberapa penelitian menyebutkan kemungkinan
viktimisasi sebagai mediator antara berat badan dan
kesehatan mental (yaitu depresi, kecemasan, masalah
emosional, harga diri, ketidakpuasan tubuh dan gangguan
makan) [14,33,34], hanya sedikit yang melakukan analisis
mediasi [35–37]. Namun, penelitian ini menggunakan sampel
kecil, desain cross-sectional atau kelompok usia muda.
Kesenjangan pengetahuan ini perlu diatasi untuk
memperoleh informasi yang dibutuhkan untuk merancang
intervensi efektif yang mempromosikan perkembangan
kesehatan mental yang sehat pada masa remaja. Oleh karena
itu kami memeriksa hubungan kelebihan berat badan
(termasuk obesitas) dan obesitas, dengan masalah psikososial
dan pikiran untuk bunuh diri, termasuk analisis peran mediasi
potensial menjadi korban intimidasi. Kami menggunakan
kombinasi pengukuran cross-sectional dan berulang (dua
gelombang) untuk sebagian responden dari sampel remaja
yang mewakili populasi besar di Amsterdam, Belanda.
Metode
sampel dan bahan
Semua sekolah menengah di Amsterdam memerlukan
penilaian kesehatan rutin siswa mereka oleh Layanan
Kesehatan Masyarakat Amsterdam (GGD). Penilaian ini
mencakup wawancara klinis dan penyelesaian kuesioner
kesehatan elektronik yang dilaporkan sendiri, sebelum
wawancara. Data dalam penelitian ini diperoleh dari
kuesioner ini dan dari Digital Child Health Care Registry
(DCHCR), yang mengelola catatan ini.
Halaman 2 dari 10
pemeriksaan fisik. Kedua sumber data tersebut merupakan
bagian dari Youth Health Monitor (YHM) dari GGD dan
dijelaskan lebih rinci di bawah ini. Kami menggabungkan tiga
kohort dari YHM. Gelombang data pertama dikumpulkan pada
tahun ajaran 2010–2011 (kelompok 1), 2011–2012 (kelompok
2), dan 2012–2013 (kelompok 3). Saat itu para siswa masih
duduk di kelas delapan, tahun kedua pendidikan menengah
Belanda ketika rata-rata siswa berusia 14 tahun. Dua tahun
kemudian, di kelas sepuluh, gelombang kedua dikumpulkan
untuk setiap angkatan.
Kuesioner kesehatan berisi pertanyaan tentang
karakteristik sosiodemografi, gaya hidup dan masalah
kesehatan fisik dan mental. Kuesioner ini diselesaikan
selama jam sekolah di ruang ujian di bawah
pengawasan seorang guru dan perawat sekolah dari
GGD. Untuk menghindari jawaban yang diinginkan
secara sosial, perawat sekolah menjelaskan kepada
siswa bahwa jawaban mereka rahasia dan hanya
diketahui oleh perawat sekolah atau mungkin dokter.
Sebelum pengumpulan data, surat informasi dikirim ke
orang tua dan siswa. Prosedur informed consent pasif
digunakan, sehingga siswa dan orang tua mereka
dapat memutuskan untuk tidak mengisi kuesioner.
Tingkat respons pada kuesioner kesehatan sekitar 90%
setiap tahun. Alasan paling umum untuk non-respon
adalah ketidakhadiran siswa pada hari kuesioner
diberikan.
sepenuhnya secara acak (Chi-Square = 0,95, DF = 2,p = .62).
Selain itu, kami menggunakan tinggi dan berat badan
yang dinilai secara objektif, dan variabel sosiodemografi
dari DCHCR. DCHCR adalah sistem pencatatan data
standar pemerintah yang mencakup informasi tentang≥.
95% dari pemuda Amsterdam. Pada penilaian kesehatan
rutin pertama anak mereka, orang tua dimintai izin untuk
menggunakan data dari DCHCR untuk tujuan penelitian
oleh GGD.
Kami mengumpulkan dan menganonimkan data dari
kuesioner dan DCHCR. Untuk menjawab pertanyaan
penelitian kami, data dari kuesioner dan DCHCR
digabungkan (Gbr. 2).1).
Pengukuran
Masalah kesehatan mental
Dua aspek kesehatan mental dinilai dalam penelitian kami:
masalah psikososial dan pikiran untuk bunuh diri.
Masalah psikososial dinilai dengan Kekuatan dan Kesulitan
Kuesioner (SDQ), yang merupakan 25-item, kuesioner
penyaringan digunakan di seluruh dunia yang meminta siswa
untuk melaporkan perilaku dan emosi mereka dalam enam
bulan terakhir. Item didistribusikan di lima skala lima item
masing-masing: gejala emosional, masalah perilaku,
hiperaktif / kurangnya perhatian, masalah hubungan teman
sebaya dan perilaku pro-sosial. Item diberi skor pada skala
Likert tiga poin ('tidak benar', 'agak benar',
Vuurendkk. Kesehatan Masyarakat BMC (2019) 19:612 Halaman 3 dari 10

Gambar 1Prosedur untuk menggabungkan data dari kuesioner elektronik dan Digital Child Health Care Registry antara tahun ajaran 2010–2011 dan
2014–2015

'pasti benar', mendapat skor 0–2). Skor kesulitan total dihitung
sebagai jumlah skor dari empat subskala pertama. Kami
berkonsentrasi pada remaja dengan skor yang relatif tinggi
(meningkat) sebagai indikator masalah psikososial serius yang
memerlukan penyelidikan lebih lanjut atau
tindakan. Untuk menentukan subkelompok, skor dikotomisasi
(peningkatan skor: total skala kesulitan> 15) berdasarkan analisis
statistik (analisis ROC dengan peningkatan skor ASEBA sebagai
kriteria) dan praktik klinis (meminimalkan kemungkinan untuk
melewatkan kasus yang sebenarnya) [38].
Vuurendkk. Kesehatan Masyarakat BMC (2019) 19:612
Studi sebelumnya telah menunjukkan validitas dan
reliabilitas yang baik dari skor total kesulitan SDQ versi
laporan diri pada remaja Belanda. Karena kekhawatiran
mengenai keandalan subskala, disarankan untuk hanya
menggunakan skor kesulitan total sebagai indikator
masalah psikososial [38–40].
Pikiran untuk bunuh diri dinilai dengan pertanyaan berikut:
“Selama 12 bulan terakhir, apakah Anda pernah berpikir serius
untuk mengakhiri hidup Anda?”, yang serupa dengan Survei
Kuesioner Perilaku Risiko Remaja dari Amerika Serikat [41].
Kategori tanggapan adalah “tidak pernah”, “jarang”, “kadang-
kadang”, “sering”, “sangat sering” dan, mirip dengan
penelitian lain tentang topik tersebut, dikotomi menjadi
“tidak” (tidak pernah) atau “ya” (kategori lain).[41,42].
Keandalan tes-tes ulang yang dapat diterima dari ukuran ini
telah ditunjukkan sebelumnya (Kappa = 0,74) [41].
Pembohongan
Kami mengukur viktimisasi dengan menanyakan “Berapa kali
Anda diintimidasi dalam tiga bulan terakhir di sekolah?”
Dengan menambahkan komponen frekuensi ke pertanyaan
ini, sifat berulang dari perilaku dimasukkan. Responden dapat
memilih dari lima kategori tanggapan: “tidak pernah”, “kurang
dari dua kali per bulan”, “dua atau tiga kali per bulan”, “sekitar
sekali seminggu”, “beberapa kali seminggu”. Operasionalisasi
ini didasarkan pada Skor Korban Bully Olweus [43]. Kami
mendikotomikan variabel ini menjadi diintimidasi setidaknya
dua kali sebulan atau tidak, sejalan dengan Solberg dan
Olweus [43,44]. Validitas dan reliabilitas yang memadai telah
dibuktikan [44].
Status berat badan
Selama penilaian kesehatan rutin mereka, berat badan dan tinggi
badan semua peserta diukur oleh asisten medis dan dicatat ke
satu tempat desimal. Jika peserta ditimbang dengan pakaian
mereka, asisten medis mengurangi berat badan mereka yang
tercatat sebesar 0,5-1,0 k, tergantung pada pakaian yang
dikenakan siswa. Baik tinggi dan berat badan diukur tanpa sepatu.
Kami membedakan tiga kelompok Indeks Massa Tubuh (BMI):
berat badan normal, kelebihan berat badan, dan obesitas
berdasarkan batas IMT International Obesity Task Force (IOTF)
untuk anak-anak [45]. Di Amsterdam, di mana prevalensi
kelebihan berat badan sekitar 20%, berat badan normal adalah
norma yang berlaku di kalangan remaja [5–7]. Untuk analisis kami
membuat dua boneka untuk status berat badan: "kelebihan berat
badan termasuk obesitas versus berat badan normal" dan
"obesitas versus berat badan normal". Seperti yang digunakan
dalam makalah ini, 'kelebihan berat badan' mengacu pada
kelebihan berat badan termasuk obesitas. Siswa dengan berat
badan kurang dikeluarkan dari analisis (Gbr.1).
sosiodemografi
Jenis kelamin dan etnis yang terdaftar di DCHCR
digunakan. Sesuai dengan definisi Statistik
Halaman 4 dari 10
Belanda, kami menganggap seorang siswa berlatar
belakang etnis non-Belanda ketika setidaknya salah satu
orang tuanya lahir di luar negeri [46]. Kami
mengkategorikan etnis ke dalam lima kelompok terbesar
di Belanda: Belanda, Suriname, Turki, Maroko, dan lainnya.
Analisis statistik
Kami menganalisis hubungan antara kelebihan berat badan
dan obesitas, dan kesehatan mental remaja, dan apakah ini
dimediasi oleh viktimisasi. Untuk beberapa siswa kami
memiliki data yang tersedia untuk T0 atau T1, dan untuk yang
lain kami memiliki data yang tersedia untuk T0 dan T1. Kami
melakukan analisis mediasi multi-level dengan struktur dua
tingkat untuk menggabungkan pengelompokan pengukuran
dalam individu. Karena penelitian kami bersifat observasional,
sudah ada hubungan antara variabel yang ditetapkan yang
kami ukur pada titik waktu pertama. Selanjutnya, data kami
dikumpulkan dengan dua tahun antara gelombang pertama
dan kedua. Karena kemungkinan besar kelebihan berat
badan, viktimisasi dan kesehatan mental saling
mempengaruhi dalam waktu yang relatif singkat [10,20], efek
kontemporer adalah representasi yang lebih baik dari
hubungan antara variabel daripada hubungan tertinggal.
Dengan menganalisis data dengan model bertingkat, kami
menggunakan semua informasi yang tersedia sambil
mempertimbangkan korelasi di antara pengukuran berulang
untuk sebagian kelompok. Dengan menggunakan dua
gelombang data untuk beberapa murid, kami mendapatkan
wawasan tentang efek di dalam dan di antara orang, yaitu
perkiraan efek dalam model kami didasarkan pada
interpretasi gabungan di dalam dan di antara subjek [47,48].
Kami memeriksa apakah sekolah harus ditambahkan sebagai
tingkat ketiga dalam analisis kami, tetapi karena korelasi intra-
kelas sangat kecil (0,02), tingkat ini diabaikan. Kelas tidak
ditambahkan sebagai tingkat cluster, karena siswa berada di
kelas yang berbeda di T0 dan T1. Selain itu, dalam sistem
pendidikan Belanda, pendidikan diberikan berdasarkan
kelompok mata pelajaran, dengan komponen umum yang
sama untuk semua siswa dan komponen pilihan. Selanjutnya,
kami menguji perbedaan yang signifikan dalam efek tidak
langsung antara anak laki-laki dan perempuan. Seks bukanlah
moderator (p <0.10).
Kami menggunakan pendekatan dua langkah untuk menganalisis
mediasi. Pertama, kami menguji efek total asli dari kelebihan berat
badan (variabel independen) pada masalah psikososial dan pikiran
untuk bunuh diri (variabel hasil). Kedua, kami memasang model di
mana kelebihan berat badan terkait dengan viktimisasi (sebuah
koefisien) dan model di mana kelebihan berat badan dan viktimisasi
terkait dengan masalah psikososial atau pikiran untuk bunuh diri (efek
langsung dan)Bkoefisien masing-masing), disesuaikan dengan jenis
kelamin dan etnis. Mediasi dihitung sebagai produk darisebuahdanB
koefisien. Interval kepercayaan (CI)untuk perkiraan efek tidak langsung
(a*b)didasarkan pada Monte Carlo
Vuurendkk. Kesehatan Masyarakat BMC (2019) 19:612 Halaman 5 dari 10

simulasi [49] untuk memperhitungkan distribusi miring dari efek
tidak langsung.
Berdasarkan studi sebelumnya [36,37] dan pada analisis sensitivitas,
kami berhipotesis bahwa remaja dengan penampilan fisik yang lebih
menyimpang dari norma, mengacu pada remaja dengan obesitas, akan
sangat rentan terhadap viktimisasi dan dengan demikian masalah
kesehatan mental. Untuk menguji hipotesis ini, kami mengulangi
semua analisis untuk remaja dengan obesitas dibandingkan dengan
rekan-rekan mereka yang memiliki berat badan normal. Semua model
dipasang menggunakan Mplus versi 7 [50] menggunakan Full
Information Maximum Likelihood untuk menangani data yang hilang.
Hasil
Karakteristik populasi
Secara total, 13.740 siswa unik dimasukkan dalam
penelitian kami. Dari 3943 siswa kami mengumpulkan
informasi di kelas 8 dan kelas 10, dan dari 9797 siswa kami
memiliki satu momen pengukuran baik dari kelas 8 atau
kelas 10 (Gbr. 1).1). Pada T0 usia rata-rata peserta adalah
14 tahun, 47% adalah laki-laki dan 40% siswa berasal dari
etnis Belanda. Juga pada T0, 18% siswa mengalami
kelebihan berat badan dan 6% obesitas, 7% siswa pernah
diintimidasi di sekolah dalam tiga bulan terakhir, 11%
memiliki masalah psikososial dan 17% memiliki pikiran
untuk bunuh diri selama 12 bulan terakhir. Lebih jelasnya
karakteristik populasi disajikan pada Tabel1.
Tabel 1Karakteristik dan distribusi variabel studi siswa kelas delapan
dan sepuluh yang berpartisipasi dalam Amsterdam Youth Health
Monitor antara tahun ajaran 2010–2011 dan 2014–2015
Kelas 8 Kelas 10 Total
Peserta (n) 10.009 7674 17.683
Usia rata-rata (tahun) 14.01 15.96 14.86
Jenis Kelamin (%)
Masalah psikososial
Dibandingkan dengan rekan-rekan mereka dengan berat
badan normal, remaja dengan kelebihan berat badan
melaporkan masalah psikososial lebih sering (efek total
asli OR: 1,5; 95% CI 1,3, 1,8) dan lebih sering menjadi
korban (sebuahkoefisien ATAU: 1,4; 95% CI 1.2, 1.7).
Remaja yang dilaporkan lebih sering diintimidasi juga
melaporkan masalah psikososial (Bkoefisien ATAU: 11.0;
95% CI 8.2, 14.7). Korban adalah mediator yang signifikan
dalam hubungan antara kelebihan berat badan dan
masalah psikososial (OR tidak langsung: 2,3; 95% CI 1,5,
3,7). Namun, viktimisasi hanya sebagian memediasi
hubungan asli antara kelebihan berat badan dan masalah
psikososial; untuk masalah psikososial efek langsung juga
tetap signifikan (efek langsung OR: 1.4; 95% CI 1.2, 1.7)
setelah efek mediasi viktimisasi ditambahkan ke model. Ini
diilustrasikan pada Gambar.2a dan file tambahan1.
Ketika kami membandingkan remaja dengan obesitas
dengan rekan-rekan mereka yang memiliki berat badan
normal, asosiasi yang dipelajari bahkan lebih kuat. Meskipun
efek langsungnya tetap sebanding (OR: 1.4; 95% CI 1.0, 2.0),
efek tidak langsungnya lebih besar (OR: 6.2; 95% CI 2.8, 14,7).
Ini diilustrasikan pada Gambar.3a dan file tambahan1.
Pikiran bunuh diri
Remaja dengan kelebihan berat badan melaporkan pikiran untuk
bunuh diri lebih sering daripada rekan berat badan normal
mereka (efek total asli OR: 1.4; 95% CI 1.2, 1.6). Remaja yang
melaporkan viktimisasi juga lebih sering melaporkan pikiran untuk
bunuh diri (Bkoefisien ATAU: 8,0; 95% CI 6.2, 10.3). Korban adalah
mediator yang signifikan dalam hubungan antara kelebihan berat
badan dan pikiran untuk bunuh diri (efek tidak langsung OR: 2.1;
95% CI 1.4, 3.2). Hubungan antara kelebihan berat badan dan
pikiran untuk bunuh diri, yaitu efek langsung, tetap signifikan
setelah efek mediasi dari viktimisasi ditambahkan ke model (OR:
1.3; 95% CI 1.1, 1.5). Ini diilustrasikan
di Gambar.2b dan file tambahan1.
Hubungan antara obesitas dan pikiran untuk bunuh diri

lebih kuat (efek tidak langsung OR: 4,5; 95% CI 2,3, 9,1 dan
47.4 45.6 46.6
efek langsung OR: 1,5; 95% CI 1,1, 2.0). Ini diilustrasikan
anak laki-laki

Cewek-cewek 52.6 54.4 53.4 pada Gambar.3b dan file tambahan1.

Etnis (%)
Belanda 39.7 40.4 40.0 Diskusi
orang Surinam 10.8 10.9 10.8 Dibandingkan dengan teman sebayanya yang memiliki berat badan normal,
remaja dengan kelebihan berat badan atau obesitas melaporkan masalah
Turki 9.0 9.2 9.0
psikososial dan pikiran untuk bunuh diri lebih sering. Asosiasi ini dimediasi
Maroko 15.8 15.3 15.6
oleh apakah remaja menjadi korban atau tidak. Efek tidak langsung ini lebih
Lainnya 24.7 24.3 24.5 kuat untuk remaja dengan obesitas dibandingkan dengan mereka yang
Kelebihan berat badan, kecuali. 18.0 16.1 17.1 kelebihan berat badan. Satu penjelasan
Obesitas (%) Obesitas, tidak termasuk. 5.5 4.7 5.2 mungkin semakin banyak tipe tubuh individu yang berbeda
Kegemukan (%) Korban intimidasi (%) 7.1 1.9 4.8 dari norma, semakin mereka menjadi korban dan semakin
kuat hubungannya dengan masalah kesehatan mental.
Masalah psikososial (%) Pikiran untuk 10.6 8.2 9.5
Penjelasan ini sejalan dengan temuan dari studi
bunuh diri (%) 16,5 9.6 13.5
sebelumnya tentang topik ini [36,37].
Vuurendkk. Kesehatan Masyarakat BMC (2019) 19:612 Halaman 6 dari 10

SEBUAH

Gambar 2.sebuahEfek langsung dan tidak langsung (melalui viktimisasi) kelebihan berat badan pada masalah psikososial, disesuaikan dengan jenis kelamin
dan etnis, Amsterdam Youth Health Monitor antara tahun ajaran 2010–2011 dan 2014–2015.BEfek langsung dan tidak langsung (melalui viktimisasi) kelebihan
berat badan pada pikiran untuk bunuh diri, disesuaikan dengan jenis kelamin dan etnis, Amsterdam Youth Health Monitor antara tahun ajaran 2010–2011 dan
2014–2015

Studi menyelidiki hubungan antara viktimisasi dan karakteristik
fisik yang relatif jarang seperti memiliki rambut merah, memakai
kacamata, cacat dan disforia gender menunjukkan temuan yang
tidak meyakinkan [51–53]. Namun, penelitian kami, bersama
dengan penelitian lain [27,28,54] menunjukkan bahwa kelebihan
berat badan adalah karakteristik fisik yang terkait dengan menjadi
korban. Ini mungkin menunjukkan bahwa kelebihan berat badan
adalah sifat khusus yang membuat remaja menonjol secara
negatif dan dengan demikian mengarah pada viktimisasi. Mungkin
kelebihan berat badan tidak hanya dilihat sebagai
sifat fisik acak, tetapi sebagai sifat dengan sosial implisit
elemen yang dapat menyebabkan stigmatisasi. Penelitian sebelumnya
tentang mengapa kelebihan berat badan dapat menyebabkan diintimidasi
menawarkan beberapa penjelasan, yang semuanya sejalan dengan gagasan
bahwa kelebihan berat badan dianggap sebagai penyimpangan dari norma
sosial [23,24]. Karena sebagian besar remaja yang tinggal di Amsterdam
tidak memiliki kelebihan berat badan atau obesitas [5–7], masuk akal bahwa
berat badan normal adalah norma di kalangan remaja. Penelitian lain telah
mengkonfirmasi hal ini dengan menunjukkan bahwa kelebihan berat badan
berpengaruh negatif
Vuurendkk. Kesehatan Masyarakat BMC (2019) 19:612 Halaman 7 dari 10

SEBUAH

Gambar 3sebuahEfek langsung dan tidak langsung (melalui viktimisasi) obesitas pada masalah psikososial, disesuaikan dengan jenis kelamin dan etnis, Amsterdam
Youth Health Monitor antara tahun ajaran 2010–2011 dan 2014–2015.BEfek langsung dan tidak langsung (melalui viktimisasi) memiliki obesitas pada pikiran untuk
bunuh diri, disesuaikan dengan jenis kelamin dan etnis, Amsterdam Youth Health Monitor antara tahun ajaran 2010–2011 dan 2014–2015

status sosial dan bahwa siswa dengan kelebihan berat badan
menerima nominasi persahabatan lebih sedikit dan lebih tidak disukai
dan lebih sering dikucilkan oleh rekan-rekan mereka [55–57].
Kerusakan sosial tersebut dapat membuat remaja dengan kelebihan
berat badan lebih rentan menjadi korban karena kurangnya teman
untuk membela mereka, harga diri yang lebih rendah, dan status sosial
yang lebih rendah di antara teman sebayanya.58,59].
Sebuah tinjauan baru-baru ini menunjukkan bahwa isolasi sosial
yang dihasilkan terkait dengan perilaku tidak sehat tambahan: asupan
makanan yang berlebihan dan penurunan partisipasi dalam olahraga
dan aktivitas fisik lainnya karena peningkatan stres.
dan tidak menikmati atau tidak berani berpartisipasi dalam kegiatan
olahraga. Selain itu, kelebihan berat badan dapat menyebabkan harga diri
yang rendah. Hal ini, pada gilirannya, dapat menyebabkan penambahan
berat badan lebih lanjut dan lingkaran setan dari hasil fisik dan sosial yang
buruk, yang sebagai konsekuensinya dapat meningkatkan kemungkinan
menjadi korban [60,61].
Selain menjadi korban bullying, mediator potensial lainnya
mungkin ketidakpuasan dengan tubuh sendiri [37] atau
berkurangnya partisipasi dalam olahraga dan aktivitas fisik [60].
Oleh karena itu, penelitian lebih lanjut dengan menggunakan
beberapa model mediasi diperlukan untuk lebih memahami
Vuurendkk. Kesehatan Masyarakat BMC (2019) 19:612
hubungan antara kelebihan berat badan dan hasil kesehatan
mental negatif pada remaja.
Penelitian sebelumnya menunjukkan bahwa skor total kesulitan
SDQ membuat perbedaan yang sangat baik antara murid yang
mungkin tidak memiliki masalah psikososial dan murid yang
memiliki, tetapi juga menunjukkan bahwa konsistensi internal dari
subskala SDQ rendah [39,40]. Perpanjangan yang bermanfaat dari
penelitian kami adalah untuk mengeksplorasi hubungan antara
kelebihan berat badan dan berbagai jenis masalah psikososial.
Kekuatan dan keterbatasan
Studi ini adalah studi skala besar pertama yang meneliti menjadi korban bullying sebagai mediator potensial dalam
hubungan antara berat badan dan masalah kesehatan mental. Sampel kami mewakili remaja di Amsterdam, daerah
perkotaan multi-etnis, dan kemungkinan besar mewakili remaja di daerah perkotaan Belanda lainnya. Kekuatan lain adalah
kombinasi dari laporan objektif tentang berat badan dan laporan diri yang divalidasi tentang viktimisasi dan masalah
kesehatan mental. Menjadi korban bullying dan masalah internalisasi kurang terlihat oleh orang tua dan guru [62–64].
Akhirnya, analisis bertingkat dalam penelitian kami memungkinkan kami untuk menggunakan semua informasi yang
tersedia dari semua peserta, terlepas dari apakah peserta memiliki informasi pada satu atau dua titik waktu.
Keterbatasannya adalah bahwa kami hanya mengeksplorasi satu mediator potensial dalam hubungan kelebihan berat
badan atau obesitas dan kesehatan mental, sedangkan mediator potensial lainnya juga dapat berperan. Kami tidak
membedakan antara jenis viktimisasi atau intensitas viktimisasi, yang dapat membantu menjelaskan hubungan yang lebih
kuat antara obesitas dan masalah mental. Mengingat sifat cross-sectional dari penelitian kami, kami tidak dapat
menyimpulkan kausalitas. Kami tidak dapat menyimpulkan apakah kelebihan berat badan menyebabkan viktimisasi dan,
selanjutnya, kondisi kesehatan mental atau apakah remaja dengan kondisi kesehatan mental lebih rentan menjadi korban
atau lebih cenderung mengalami kelebihan berat badan. Penelitian lebih lanjut diperlukan untuk menguji hubungan kausal
antara kelebihan berat badan dan masalah kesehatan mental dan peran yang mungkin dimainkan oleh viktimisasi dan
faktor lain dalam hubungan ini. Akhirnya, kami tidak menggunakan pertanyaan viktimisasi berdasarkan bobot tertentu,
sehingga kemungkinan viktimisasi yang diukur dapat disebabkan oleh faktor lain seperti faktor kepribadian yang
menggarisbawahi viktimisasi dan masalah kesehatan mental. Untuk penelitian masa depan akan menjadi nilai tambah untuk
menggunakan konstruksi 'viktimisasi berbasis bobot' seperti yang dikembangkan dan dipelajari oleh Puhl et al. [ Penelitian
lebih lanjut diperlukan untuk menguji hubungan kausal antara kelebihan berat badan dan masalah kesehatan mental dan
peran yang mungkin dimainkan oleh viktimisasi dan faktor lain dalam hubungan ini. Akhirnya, kami tidak menggunakan
pertanyaan viktimisasi berdasarkan bobot tertentu, sehingga kemungkinan viktimisasi yang diukur dapat disebabkan oleh
faktor lain seperti faktor kepribadian yang menggarisbawahi viktimisasi dan masalah kesehatan mental. Untuk penelitian
masa depan akan menjadi nilai tambah untuk menggunakan konstruksi 'viktimisasi berbasis bobot' seperti yang
dikembangkan dan dipelajari oleh Puhl et al. [ Penelitian lebih lanjut diperlukan untuk menguji hubungan kausal antara
kelebihan berat badan dan masalah kesehatan mental dan peran yang mungkin dimainkan oleh viktimisasi dan faktor lain
dalam hubungan ini. Akhirnya, kami tidak menggunakan pertanyaan viktimisasi berdasarkan bobot tertentu, sehingga
kemungkinan viktimisasi yang diukur dapat disebabkan oleh faktor lain seperti faktor kepribadian yang menggarisbawahi
viktimisasi dan masalah kesehatan mental. Untuk penelitian masa depan akan menjadi nilai tambah untuk menggunakan
konstruksi 'viktimisasi berbasis bobot' seperti yang dikembangkan dan dipelajari oleh Puhl et al. [ jadi ada kemungkinan
bahwa viktimisasi yang terukur dapat disebabkan oleh faktor lain seperti faktor kepribadian yang menggarisbawahi
viktimisasi dan masalah kesehatan mental. Untuk penelitian masa depan akan menjadi nilai tambah untuk menggunakan
konstruksi 'viktimisasi berbasis bobot' seperti yang dikembangkan dan dipelajari oleh Puhl et al. [ jadi ada kemungkinan
bahwa viktimisasi yang terukur dapat disebabkan oleh faktor lain seperti faktor kepribadian yang menggarisbawahi
viktimisasi dan masalah kesehatan mental. Untuk penelitian masa depan akan menjadi nilai tambah untuk menggunakan
konstruksi 'viktimisasi berbasis bobot' seperti yang dikembangkan dan dipelajari oleh Puhl et al. [30,65].
Kesimpulan
Studi kami menunjukkan bahwa kelebihan berat badan dan obesitas
secara signifikan terkait dengan masalah kesehatan mental di
Halaman 8 dari 10
remaja, dan bahwa menjadi korban bullying berperan dalam asosiasi
ini. Oleh karena itu, kami menyarankan untuk mengatasi stigma sosial
dan viktimisasi dalam program pencegahan yang mempromosikan
gaya hidup sehat untuk meningkatkan integrasi sosial dan kualitas
hidup secara keseluruhan [56]. Misalnya, mengintegrasikan masalah
yang berkaitan dengan stigma sosial dan viktimisasi dalam program
yang ditujukan untuk makan sehat, aktivitas fisik, dan mencegah
kelebihan berat badan dapat menghasilkan sikap yang lebih positif
terhadap teman sebaya dengan kelebihan berat badan atau obesitas,
yang dapat mengarah pada peningkatan kesehatan mental mereka
secara keseluruhan. Tanpa memperhatikan kesejahteraan mental
remaja, program pencegahan yang didasarkan secara sempit pada
keseimbangan energi dan pengendalian berat badan dapat terlalu
menekankan konsekuensi negatif dari kelebihan berat badan atau
obesitas, sedangkan fokus yang lebih positif pada upaya dan
kemampuan untuk mengontrol gaya hidup sendiri dapat lebih efektif
dalam mempromosikan kesehatan secara keseluruhan. Dari perspektif
yang berbeda, intervensi dan program yang ditujukan untuk mencegah
viktimisasi dan/atau merangsang kesehatan mental juga harus
menyadari pengaruh kelebihan berat badan dan obesitas.
File tambahan
File tambahan 1:tabel regresi. (PDF 208kb)
Singkatan
ASEBA:Sistem Penilaian Berbasis Empiris Achenbach; BMI: Indeks Massa Tubuh; CI:
Interval Keyakinan; DCHCR: Pendaftaran Perawatan Kesehatan Anak Digital; GGD:
Layanan Kesehatan Masyarakat Amsterdam; IOTF: Gugus Tugas Obesitas Internasional;
ATAU: Rasio Peluang; SDQ: Kuesioner Kekuatan dan Kesulitan;
YHM: Pemantau Kesehatan Pemuda
ucapan terima kasih
Para penulis mengucapkan terima kasih yang sebesar-besarnya atas bantuan karyawan
departemen Perawatan Kesehatan Anak dari Layanan Kesehatan Masyarakat Amsterdam dalam
mengimplementasikan Monitor Kesehatan Pemuda dan kepada semua orang yang bekerja dalam
proyek ini untuk mewujudkannya. Mereka ingin mengucapkan terima kasih kepada semua
sekolah dan siswa atas partisipasi mereka, HM (Hans) Koot atas sarannya tentang aspek
substantif dari teks dan JWR (Jos) Twisk atas saran statistiknya.
Pendanaan
Tidak ada. Penulis atau institusinya tidak setiap saat menerima pembayaran atau layanan
dari pihak ketiga untuk aspek apa pun dari karya yang dikirimkan. Mereka tidak terlibat
dalam aktivitas keuangan yang relevan di luar karya yang dikirimkan dan tidak memiliki
hubungan/kondisi/keadaan lain yang berpotensi menimbulkan konflik kepentingan.
Ketersediaan data dan bahan
Kumpulan data yang dianalisis selama penelitian saat ini tersedia dari penulis
terkait atas permintaan yang masuk akal.
Kontribusi penulis
CLvV mengoordinasikan pengumpulan data, berkontribusi pada konsep dan
desain, melakukan analisis statistik, menafsirkan data, dan menyusun
naskah. GGW berkontribusi pada konsep dan desain, analisis statistik dan
interpretasi data. VB membuat konsep penelitian dan memberikan saran
statistik. RV telah berkontribusi pada bagian diskusi dengan
pengetahuannya yang luas tentang viktimisasi teman sebaya. JJMR
memberikan saran statistik yang ekstensif dan berkontribusi pada
penyusunan bagian metode. MFvdW dan MJMC mengawasi konseptualisasi
studi dan analisis statistik. Semua penulis berkontribusi pada revisi kritis
naskah dan telah menyetujui versi final.
Vuurendkk. Kesehatan Masyarakat BMC (2019) 19:612
Persetujuan etika dan persetujuan untuk berpartisipasi
Studi ini terdaftar di Otoritas Perlindungan Data Belanda dan memenuhi
persyaratan etika dan privasi nasional. Sebelum pengumpulan data, surat
informasi dikirim ke orang tua dan siswa. Prosedur informed consent pasif
digunakan, sehingga siswa dan orang tua mereka dapat memutuskan untuk tidak
mengisi kuesioner. Metode perjanjian pasif ini sesuai dengan standar hukum
Belanda. Persetujuan etik medis diminta dari Komite Peninjauan Etika Medis dari
Pusat Medis Akademik Amsterdam (AMC) sebelum analisis; namun, permintaan
kami tidak dianggap sebagai studi observasional pada data yang dianonimkan
tidak tunduk pada persetujuan etis.
Persetujuan untuk publikasi Tak
dapat diterapkan.
Kepentingan yang bersaing
Para penulis menyatakan bahwa mereka tidak memiliki kepentingan yang bersaing.
Catatan Penerbit
Springer Nature tetap netral sehubungan dengan klaim yurisdiksi dalam
peta yang diterbitkan dan afiliasi institusional.
Detail penulis
1Departemen Epidemiologi, Promosi Kesehatan dan Inovasi Perawatan Kesehatan,
Layanan Kesehatan Masyarakat (GGD) Amsterdam, Nieuwe Achtergracht 100, 1018
WT Amsterdam, Belanda.2Departemen Sosiologi, Fakultas Ilmu Perilaku dan Sosial,
Universitas Groningen, Grote Kruisstraat 1/2, 9712 TS Groningen, Belanda.3
Department of Epidemiology and Biostatistics, Amsterdam Public Health Research
Institute, Amsterdam UMC, lokasi VU University Medical Center, PO BOX 7057,
1007 MB Amsterdam, Belanda.4Departemen Kesehatan Masyarakat dan Pekerjaan,
Institut Penelitian Kesehatan Masyarakat Amsterdam, Amsterdam UMC, Vrije
Universiteit Amsterdam, PO BOX 7057, 1007 MB, Amsterdam, Belanda.
Diterima: 5 Juli 2018 Diterima: 15 April 2019
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https://doi.org/10.1186/s12889-019-6832-z

RESEARCH ARTICLE Open Access

Associations between overweight and

mental health problems among
adolescents, and the mediating role of
victimization
Cornelia Leontine van Vuuren1,4* , Gusta G. Wachter1, René Veenstra2, Judith J. M. Rijnhart3, Marcel F. van der Wal1,
Mai J. M. Chinapaw4 and Vincent Busch1

Abstract
Background: Evidence has not been conclusive on whether adolescent overweight is associated with mental
health, possibly caused by indirect, yet untested associations. Therefore, the purpose of this study was to examine the
association between overweight or obesity and mental health problems among adolescents, and to determine
whether victimization plays a mediating role in these associations.
Methods: Self-reported data on mental health and victimization and objectively measured Body Mass Index data were
used, using three cohorts (2010–2011 until 2012–2013) and an interval between the measurement waves of two years
later. We performed a multi-level mediation analysis with a two-level structure to incorporate the clustering of the
measurements within individuals. The study population consisted of 13,740 secondary school students, 13–14 years old
at the first measurement moment, in Amsterdam, the Netherlands.
Results: Compared to their normal-weight peers, adolescents with overweight or obesity reported psychosocial
problems and suicidal thoughts more often. Victimization was a significant mediator in the relationship between
having overweight, and psychosocial problems (indirect effect OR: 2.3; 95% CI 1.5, 3.7 and direct effect OR: 1.4; 95% CI
1.2, 1.7) or suicidal thoughts (indirect effect OR: 2.1; 95% CI 1.4, 3.2 and direct effect OR: 1.3; 95% CI 1.1, 1.5).
The associations between obesity, and psychosocial problems (indirect OR: 6.2; 95% CI 2.8, 14.7 and direct
effect OR: 1.4; 95% CI 1.0, 2.0), or suicidal thoughts (indirect OR: 4.5; 95% CI 2.3, 9.1 and direct effect OR: 1.5;
95% CI 1.1, 2.0) were even stronger.
Conclusions: Overweight and obesity were significantly associated with mental health problems in
adolescents, and victimization played a mediating role in this association. Victimization and mental health
should be integrated into prevention programs that address healthy weight development. Moreover,
overweight should be given more attention in programs to prevent victimization and promote adolescent
mental health.
Keywords: Overweight, Obesity, Mental health problems, Bullying victimization, Youth

* Correspondence: lvvuuren@ggd.amsterdam.nl
1
Department of Epidemiology, Health Promotion and Healthcare Innovation,
Public Health Service (GGD) Amsterdam, Nieuwe Achtergracht 100, 1018 WT
Amsterdam, the Netherlands
4
Department of Public and Occupational Health, Amsterdam Public Health
Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. BOX
7057, 1007 MB, Amsterdam, the Netherlands
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Vuuren et al. BMC Public Health (2019) 19:612
Background
Adolescent overweight is a widespread phenomenon [1, 2].
In 2016, globally around 17% of teenagers had overweight,
including obesity [3]. In the Netherlands, around 15% of
the 14-and 16-years-olds have overweight [4] and in
Amsterdam the prevalence is around 20% [5–7]. Adoles-
cent overweight, besides affecting physical health, may
negatively impact mental health. However, evidence has not
been conclusive on whether adolescent overweight is asso-
ciated with psychosocial problems and suicidal thoughts.
Several studies have found an association with mental
health problems, such as depression, suicide ideation and
attempts, anxiety, behavioral problems, low self-esteem and
poor self-image [8–14], whereas other studies found no evi-
dence of such associations [15–18].
These inconsistent findings might be caused by in-
direct associations between both overweight and
obesity and mental health problems that have not
been tested [19]. A possible mediator is victimization
[20–22]. Being overweight is not in line with the
prevailing Western cultural norms and ideals about
physical appearance [23]. Adolescents with over-
weight stand out negatively and often develop a poor
self-image, which increases their risk of being bullied
by peers [24–32]. Although some studies mentioned
the possibility of victimization as a mediator between
body weight and mental health (i.e. depression,
anxiety, emotional problems, self-esteem, body
dissatisfaction and eating disorders) [14, 33, 34], only
a few have conducted mediation analyses [35–37].
However, these studies used small samples, cross-
sectional designs or young age groups.
This knowledge gap needs to be addressed to acquire
the information needed to design effective interventions
promoting healthy mental health development in adoles-
cence. We therefore examined the association of over-
weight (including obesity) and obesity, with psychosocial
problems and suicidal thoughts, including an analysis of
the potential mediating role of being a victim of
bullying. We used a combination of cross-sectional and
repeated measurements (two waves) for a subset of re-
spondents from a large, population-representative sam-
ple of adolescents in Amsterdam, the Netherlands.
Methods
Sample and materials
All secondary schools in Amsterdam require routine
health assessments of their students by the Amsterdam
Public Health Service (GGD). This assessment includes
a clinical interview and completion of a self-reported
electronic health questionnaire, before the interview.
The data in this study were obtained from this question-
naire and from the Digital Child Health Care Registry
(DCHCR), which administers the records of these
Page 2 of 10
physical examinations. Both data sources are part of the
Youth Health Monitor (YHM) of the GGD and are
described in more detail below. We combined three co-
horts from the YHM. The first data wave was collected
in school years 2010–2011 (cohort 1), 2011–2012
(cohort 2), and 2012–2013 (cohort 3). At that time the
students were in the eighth grade, the second year of
Dutch secondary education when students are on aver-
age 14 years old. Two years later, in the tenth grade, the
second wave was collected for each cohort.
The health questionnaire contained questions about
sociodemographic characteristics, lifestyles and physical
and mental health problems. These questionnaires were
completed during school hours in an exam room under
supervision of a teacher and a school nurse of the GGD.
To avoid socially desirable answers, the school nurse ex-
plained to the students that their answers were confi-
dential and were known only to the school nurse or
possibly a physician. Before data collection, information
letters were sent to parents and students. A passive in-
formed consent procedure was used, so students and
their parents could decide not to complete the question-
naire. The response rate on the health questionnaire was
around 90% annually. The most common reason for
non-response was absence of the student on the day the
questionnaire was given. Based on Little’s MCAR Test in
SPSS, we determined that missing data were missing
completely at random (Chi-Square = .95, DF = 2, p = .62).
In addition, we used objectively assessed body height
and weight, and sociodemographic variables from the
DCHCR. The DCHCR is a standard government data
registry system that includes information on ≥95% of
Amsterdam’s youth. At their child’s first routine health
assessment, parents are asked for their permission to use
data from the DCHCR for research purposes by the
GGD.
We aggregated and anonymised the data from the
questionnaires and the DCHCR. To answer our research
questions, data from the questionnaires and DCHCR
were merged (Fig. 1).
Measures
Mental health problems
Two aspects of mental health were assessed in our
study: psychosocial problems and suicidal thoughts.
Psychosocial problems were assessed by the Strengths
and Difficulties Questionnaire (SDQ), which is a 25-
item, worldwide used screening questionnaire that asks
students to report on their behaviors and emotions in
the past six months. The items are distributed across
five scales of five items each: emotional symptoms, con-
duct problems, hyperactivity/inattention, peer relation-
ship problems and pro-social behavior. Items are scored
on a three-point Likert scale (‘not true’, ‘somewhat true’,
Vuuren et al. BMC Public Health (2019) 19:612 Page 3 of 10

Fig. 1 Procedure for merging data from the electronic questionnaire and the Digital Child Health Care Registry between school years 2010–2011
and 2014–2015

‘certainly true’, scored 0–2). A total difficulties score was
calculated as the sum of scores of the first four sub-
scales. We concentrate on adolescents with a relatively
high (elevated) score as an indicator of serious psycho-
social problems which needed further investigation or
action. To determine subgroups, the scores were dichoto-
mized (elevated score: total difficulties scale > 15) based
on statistical analyses (ROC-analyses with elevated
ASEBA scores as the criterion) and clinical practice
(minimizing the chance to miss true cases) [38].
Vuuren et al. BMC Public Health (2019) 19:612
Previous studies have shown good validity and reliabil-
ity of the SDQ total difficulties score self-report version
in Dutch adolescents. Due to concerns regarding the re-
liability of the subscales, it is recommended to use only
the total difficulties score as an indicator of psychosocial
problems [38–40].
Suicidal thoughts were assessed with the following
question: “During the past 12 months, have you ever ser-
iously thought about ending your life?”, which is similar
to the Youth Risk Behavior Questionnaire Survey from
the USA [41]. The response categories were “never”,
“rarely”, “sometimes”, “often”, “very often” and, similar
to other studies on the topic, dichotomized into “no”
(never) or “yes” (other categories). [41, 42]. Acceptable
test-retest reliability of this measure was previously
demonstrated (Kappa = .74) [41].
Victimization
We measured victimization by asking “How many times
have you been bullied in the past three months at
school?” By adding a frequency component to this ques-
tion the repeated nature of the behavior was included.
Respondents could choose from five response categories:
“never”, “less than twice per month”, “two or three times
per month”, “about once a week”, “several times a week”.
This operationalization was based on the Olweus Bully
Victim Score [43]. We dichotomized this variable into
being bullied at least twice a month or not, in line with
Solberg and Olweus [43, 44]. Adequate validity and
reliability have been demonstrated [44].
Weight status
During their routine health assessment, all participants’
body weight and height were measured by a medical as-
sistant and recorded to one decimal place. If participants
were weighted with their clothes on, the medical assist-
ant reduced their recorded weight by 0.5 to 1.0 k, de-
pending on the clothes the student was wearing. Both
height and weight were measured without shoes. We
distinguished three Body Mass Index (BMI) groups: nor-
mal weight, overweight, and obesity based on Inter-
national Obesity Task Force (IOTF) BMI cutoffs for
children [45]. In Amsterdam, where the overweight
prevalence is around 20%, normal weight is the prevail-
ing norm among adolescents [5–7]. For the analysis we
created two dummies for weight status: “overweight in-
cluding obesity versus normal weight” and “obese versus
normal weight”. As used in this paper, ‘overweight’ refers
to overweight including obesity. Students with under-
weight were excluded from the analysis (Fig. 1).
Sociodemographics
Sex and ethnicity as registered in the DCHCR were used.
In accordance with the definition of Statistics
Page 4 of 10
Netherlands, we considered a student to be of
non-Dutch ethnic background when at least one parent
was foreign-born [46]. We categorized ethnicity into
the five largest groups in the Netherlands: Dutch,
Surinamese, Turkish, Moroccan and other.
Statistical analyses
We analyzed the association between overweight and
obesity, and adolescents’ mental health, and whether this
was mediated by victimization. For some students we
had data available for either T0 or T1, and for others we
had data available for both T0 and T1. We performed a
multi-level mediation analysis with a two-level structure
to incorporate the clustering of the measurements
within individuals. As our study was observational, there
was already a relationship between the variables estab-
lished that we measured at time point one. Furthermore,
our data was collected with two years between the first
and second wave. As it was more likely that overweight,
victimization and mental health influenced each other in
a relatively short period of time [10, 20], the contempor-
aneous effects were a better representation of the rela-
tionships between the variables than the lagged
relationships. By analyzing the data with a multilevel
model we used all available information while taking
into account the correlation among the repeated mea-
sures for part of the group. By using two waves of data
for some of the pupils we get insight in both the within-
and between-person effect, i.e. the effect estimates in
our models were based on a combined within- and
between-subject interpretation [47, 48]. We checked
whether schools should be added as a third level in our
analyses, but because the intra-class correlation was very
small (.02) this level was disregarded. Class was not
added as a cluster level, because students were in differ-
ent classes in T0 and T1. Moreover, in the Dutch educa-
tion system, education is given on the basis of subject
clusters, with a general component that is the same
for all pupils and an elective component. Further-
more, we tested for significant differences in the in-
direct effects between boys and girls. Sex was not a
moderator (p < 0.10).
We used a two-step approach to analyze mediation. First,
we examined the original total effect of overweight (inde-
pendent variable) on psychosocial problems and suicidal
thoughts (outcome variables). Second, we fitted a model in
which overweight was related to victimization (a coeffi-
cient) and a model in which overweight and victimization
were related to psychosocial problems or suicidal thoughts
(direct effect and b coefficient respectively), adjusted for sex
and ethnicity. Mediation was calculated as the product of
the a and b coefficients. Confidence intervals (CI) for the
indirect effect estimates (a*b) were based on Monte Carlo
Vuuren et al. BMC Public Health (2019) 19:612 Page 5 of 10

simulations [49] to account for the skewed distribution of Psychosocial problems

the indirect effect. Compared to their normal-weight peers, adolescents
Based on previous studies [36, 37] and on a sensitivity with overweight reported psychosocial problems more
analysis, we hypothesized that adolescents with a more often (original total effect OR: 1.5; 95% CI 1.3, 1.8) and
norm-deviating physical appearance, referring to adoles- victimization more often (a coefficient OR: 1.4; 95% CI
cents with obesity, would be especially vulnerable to 1.2, 1.7). Adolescents who reported being bullied more
victimization and thereby to mental health problems. To often also reported psychosocial problems (b coefficient
test this hypothesis, we repeated all analyses for adoles- OR: 11.0; 95% CI 8.2, 14.7). Victimization was a signifi-
cents with obesity in comparison to their normal weight cant mediator in the relationship between having over-
peers. All models were fitted using Mplus version 7 [50] weight and psychosocial problems (indirect OR: 2.3; 95%
using the Full Information Maximum Likelihood for CI 1.5, 3.7). However, victimization only partly mediated
handling missing data. the original association between having overweight and
psychosocial problems; for psychosocial problems the
direct effect also remained significant (direct effect OR:
Results 1.4; 95% CI 1.2, 1.7) after the mediation effect of
Population characteristics victimization was added to the model. This is illustrated
In total, 13,740 unique students were included in our in Fig. 2a and Additional file 1.
study. From 3943 students we gathered information in When we compared adolescents with obesity to
grade 8 and grade 10, and from 9797 students we had their normal weight peers, the studied associations
one measurement moment from either grade 8 or grade were even stronger. Although the direct effect
10 (Fig. 1). At T0 the mean age of the participants was remained comparable (OR: 1.4; 95% CI 1.0, 2.0), the
14 years, 47% were male and 40% of the students were indirect effect was larger (OR: 6.2; 95% CI 2.8, 14.7).
of Dutch ethnic origin. Also at T0, 18% of the students This is illustrated in Fig. 3a and Additional file 1.
had overweight and 6% obesity, 7% of the students had
been bullied at school in the past three months, 11% had Suicidal thoughts
psychosocial problems and 17% had suicidal thoughts Adolescents with overweight reported suicidal thoughts
during the past 12 months. More details on population more often than their normal weight peers (original total
characteristics are presented in Table 1. effect OR: 1.4; 95% CI 1.2, 1.6). Adolescents who reported
victimization also reported suicidal thoughts more often
(b coefficient OR: 8.0; 95% CI 6.2, 10.3). Victimization was
a significant mediator in the relationship between having
Table 1 Characteristics and distribution of study variables of eighth overweight and suicidal thoughts (indirect effect OR: 2.1;
and tenth grade students participating in the Amsterdam Youth 95% CI 1.4, 3.2). The association between overweight and
Health Monitor between school years 2010–2011 and 2014–2015 suicidal thoughts, i.e. the direct effect, remained signifi-
Grade 8 Grade 10 Total cant after the mediation effect of victimization was added
Participants (n) 10,009 7674 17,683 to the model (OR: 1.3; 95% CI 1.1, 1.5). This is illustrated
Mean age (years) 14.01 15.96 14.86 in Fig. 2b and Additional file 1.
Sex (%)
The associations between obesity and suicidal
thoughts were stronger (indirect effect OR: 4.5; 95% CI
Boys 47.4 45.6 46.6
2.3, 9.1 and direct effect OR: 1.5; 95% CI 1.1, 2.0). This
Girls 52.6 54.4 53.4 is illustrated in Fig. 3b and Additional file 1.
Ethnicity (%)
Dutch 39.7 40.4 40.0 Discussion
Surinamese 10.8 10.9 10.8 Compared to their normal weight peers, adolescents with
Turkish 9.0 9.2 9.0
overweight or obesity reported psychosocial problems and
suicidal thoughts more often. These associations were me-
Moroccan 15.8 15.3 15.6
diated by whether or not the adolescents were victimized.
Other 24.7 24.3 24.5 This indirect effect was stronger for adolescents with
Overweight, excl. Obese (%) 18.0 16.1 17.1 obesity than for those with overweight. One explanation
Obese, excl. Overweight (%) 5.5 4.7 5.2 may be that the more an individual’s body type diverges
Bullying victimization (%) 7.1 1.9 4.8 from the norm, the more they are victimized and the
Psychosocial problems (%) 10.6 8.2 9.5
stronger the association with mental health problems be-
comes. This explanation is in line with the findings from
Suicidal thoughts (%) 16.5 9.6 13.5
earlier studies on this topic [36, 37].
Vuuren et al. BMC Public Health (2019) 19:612 Page 6 of 10

Fig. 2 a Direct and indirect effects (through victimization) of having overweight on psychosocial problems, adjusted for sex and ethnicity,
Amsterdam Youth Health Monitor between school years 2010–2011 and 2014–2015. b Direct and indirect effects (through victimization) of
having overweight on suicidal thoughts, adjusted for sex and ethnicity, Amsterdam Youth Health Monitor between school years 2010–2011
and 2014–2015

Studies investigating the relationship between
victimization and relatively uncommon physical charac-
teristics such as having red hair, wearing glasses, disabil-
ities and gender dysphoria demonstrated inconclusive
findings [51–53]. However, our study, along with other
research [27, 28, 54] shows that overweight is a physical
characteristic that is related to being victimized. This
may indicate that overweight is a specific trait that
makes adolescents stand out negatively and thus leads to
victimization. Perhaps overweight is seen as not just as a
random physical trait, but as a trait with implicit social
elements that may lead to stigmatization. Previous re-
search on why overweight may lead to being bullied of-
fered several explanations, which are all in line with the
idea that overweight is perceived as a deviation from the
social norm [23, 24]. As the large majority of the
adolescents living in Amsterdam do not have overweight
or obesity [5–7], it is plausible that normal weight is the
norm among adolescents. Other studies have confirmed
this by showing that overweight negatively influences
Vuuren et al. BMC Public Health (2019) 19:612 Page 7 of 10

Fig. 3 a Direct and indirect effects (through victimization) of having obesity on psychosocial problems, adjusted for sex and ethnicity, Amsterdam
Youth Health Monitor between school years 2010–2011 and 2014–2015. b Direct and indirect effects (through victimization) of having obesity on
suicidal thoughts, adjusted for sex and ethnicity, Amsterdam Youth Health Monitor between school years 2010–2011 and 2014–2015

social status and that pupils with overweight received
fewer friendship nominations and were more disliked
and more often excluded by their peers [55–57]. Such
social damage can make adolescents with overweight
more vulnerable to being victimized due to a lack of
friends to defend them, lower self-esteem, and a lower
social status among their peers [58, 59].
A recent review showed that the resulting social isola-
tion is related to additional unhealthy behaviors: exces-
sive food intake and decreased participation in sports
and other physical activities because of increased stress
and not enjoying or daring to participate in sports activ-
ities. Furthermore, overweight can lead to a low
self-esteem. This can, in turn, lead to further weight gain
and a vicious cycle of poor physical and social outcomes,
which as a consequence could enhance the probability
to become a victim [60, 61].
Besides being a victim of bullying, other potential me-
diators may be dissatisfaction with one’s own body [37]
or reduced participation in sports and physical activity
[60]. Therefore, further research using multiple medi-
ation models is needed to better understand the
Vuuren et al. BMC Public Health (2019) 19:612
relationship between overweight and negative mental
health outcomes in adolescents.
Previous research demonstrated that the SDQ total
difficulties score makes an excellent distinction between
pupils who probably have no psychosocial problems and
pupils who do, but also showed that the internal
consistency of the SDQ subscales is low [39, 40]. A fruit-
ful extension of our research would be to explore the as-
sociation between overweight and different types of
psychosocial problems.
Strengths and limitations
This study is the first large-scale study examining being
a victim of bullying as a potential mediator in the associ-
ation between body weight and mental health problems.
Our sample is representative for adolescents in
Amsterdam, a multi-ethnic urban area, and likely repre-
sentative for adolescents in other Dutch urban areas.
Another strength is the combination of an objective re-
port of body weight and validated self-reports of
victimization and mental health problems. Being a vic-
tim of bullying and internalizing problems are less ap-
parent to parents and teachers [62–64]. Finally, the
multilevel analyses in our study allowed us to use all
available information from all participants, regardless of
whether a participant had information on one or two
time points. A limitation is that we explored only one
potential mediator in the relationship of overweight or
obesity and mental health, whereas other potential medi-
ators could also play a role. We did not distinguish be-
tween types of victimization or intensity of
victimization, which may help to explain the stronger as-
sociation between obesity and mental problems. Given
the cross-sectional nature of our study, we were not able
to infer causality. We could not infer whether over-
weight caused victimization and, subsequently, mental
health conditions or whether adolescents with mental
health conditions were more vulnerable to becoming
victimized or more inclined to develop overweight. Fur-
ther research is needed to examine the causal relation
between overweight and mental health problems and the
role that victimization and other factors may play in this
relationship. Finally, we did not use a specific weight
based victimization question, so it is possible that the
measured victimization could be caused by other factors
such as personality factors underlining victimization and
mental health problems. For future research it would be
of added value to use the construct of ‘weight based
victimization’ as developed and studied by Puhl et al.
[30, 65].
Conclusions
Our study shows that overweight and obesity are signifi-
cantly associated with mental health problems in
Page 8 of 10
adolescents, and that being a victim of bullying plays a
role in this association. Therefore, we suggest addressing
social stigma and victimization in prevention programs
that promote a healthy lifestyle to improve social inte-
gration and overall quality of life [56]. For example, inte-
grating issues relating to social stigma and victimization
within programs aimed at healthy eating, physical activ-
ity and preventing overweight might result in more posi-
tive attitudes towards peers with overweight or obesity,
which may lead to an improvement in their overall men-
tal health. Without such regard for adolescents’ mental
well-being, the prevention programs based narrowly on
energy balance and weight control may over-emphasize
the negative consequences of overweight or obesity,
whereas a more positive focus on the effort and ability
to control one’s own lifestyle may be more effective in
promoting overall health. From a different perspective,
interventions and programs aimed at preventing
victimization and/or stimulating mental health should
also be aware of the influence of overweight and obesity.
Additional file
Additional file 1: Regression tables. (PDF 208 kb)
Abbreviations
ASEBA: Achenbach System of Empirically Based Assessment; BMI: Body Mass
Index; CI: Confidence Interval; DCHCR: Digital Child Health Care Registry;
GGD: Amsterdam Public Health Service; IOTF: International Obesity Task
Force; OR: Odds Ratio; SDQ: Strengths and Difficulties Questionnaire;
YHM: Youth Health Monitor
Acknowledgements
The authors gratefully acknowledge the assistance of the employees of the
Child Health Care department from the Amsterdam Public Health Service in
implementing the Youth Health Monitor and to everyone who worked on
this project to make it possible. They would like to thank all schools and
students for their participation, H.M. (Hans) Koot for his advice on
substantive aspects of the text and J.W.R (Jos) Twisk for his statistical advice.
Funding
None. The authors or their institutions did not at any time receive payment
or services from a third party for any aspect of the submitted work. They
were not involved in relevant financial activities outside the submitted work
and had no other relationships/conditions/circumstances that present a
potential conflict of interest.
Availability of data and materials
The dataset analysed during the current study is available from the
corresponding author on reasonable request.
Authors’ contributions
C.L.v.V. coordinated the data collection, contributed to the concept and
design, performed the statistical analyses, interpreted the data and drafted
the manuscript. G.G.W. contributed to the concept and design, the statistical
analyses and interpretation of the data. V.B. conceptualized the study and
provided statistical advice. R.V. has contributed to the discussion section by
his extensive knowledge about peer victimization. J.J.M.R. provided extensive
statistical advice and contributed to the drafting of the method section.
M.F.v.d.W and M.J.M.C supervised the conceptualization of the study and the
statistical analyses. All authors contributed to critical revisions of the
manuscript and have approved the final version.
Vuuren et al. BMC Public Health (2019) 19:612
Ethics approval and consent to participate
This study is registered at the Dutch Data Protection Authority and meets
national ethics and privacy requirements. Before data collection, information
letters were sent to parents and students. A passive informed consent
procedure was used, so students and their parents could decide to not to
complete the questionnaire. This method of passive agreement is in
accordance with Dutch legal standards. Medical ethical approval was sought
from the Medical Ethical Review Committee of the Amsterdam Academic
Medical Centre (AMC) before analysis; however, our request was not
considered as observational studies on anonymised data are not subject for
ethical approval.
Consent for publication
Not applicable.
Competing interests
The authors declare they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Epidemiology, Health Promotion and Healthcare Innovation,
Public Health Service (GGD) Amsterdam, Nieuwe Achtergracht 100, 1018 WT
Amsterdam, the Netherlands. 2Department of Sociology, Faculty of
Behavioral and Social Sciences, University of Groningen, Grote Kruisstraat 2/1,
9712 TS Groningen, the Netherlands. 3Department of Epidemiology and
Biostatistics, Amsterdam Public Health Research Institute, Amsterdam UMC,
location VU University Medical Center, P.O. BOX 7057, 1007 MB Amsterdam,
the Netherlands. 4Department of Public and Occupational Health,
Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije
Universiteit Amsterdam, P.O. BOX 7057, 1007 MB, Amsterdam, the
Netherlands.
Received: 5 July 2018 Accepted: 15 April 2019
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Jurnal Gizi Klinik Indonesia, Vol. 12, No. 4, April 2016: 138-143
Jurnal Gizi Klinik Indonesia
Vol 12 No 4 - April 2016 (138-143)
ISSN 1693-900X (Print), ISSN 2502-4140 (Online)
Tersedia online sejak Januari 2016 di https://jurnal.ugm.ac.id/jgki

Depresi, ansietas, dan stres serta hubungannya dengan obesitas pada

remaja
Relationship of depression, anxiety and stress with obesity in adolescent
Huriatul Masdar1, Pragita Ayu Saputri1, Dani Rosdiana1, Fifia Chandra, Darmawi1

Fakultas Kedokteran Universitas Riau

ABSTRACT
Background: Obesity can occur in all ages, including adolescents. Multiple factors were known related to obesity including
psychological factor. Eating excessively could be response toward loneliness, grief or depression. Anxiety can contribute to determine
the food intake and nutrient substance, and stress can cause behavioural disorders such as abnormal (excessive) eating behaviour
that leads to obesity. Objective: The aimed of this research was to know depression, anxiety and stress and their relationship with
obesity in adolescents in Pekanbaru. Method: A cross sectional research was performed, involving 132 subjects taken from 7
of 14 State Senior High Schools in Pekanbaru, 66 subjects were oerweight/obes and 66 subjects were normal. Body mass index
per age was used to determine their nutritional status according to Indonesian Ministry of Health Standard 2010 for nutritional
status of 5-18 years old children. Depression, anxiety and stress were measured by using DASS 42 scale, and categorized only into
normal or having depression/anxiety/stress. Data were statistically analyzed by using Chi-Square test with significancy level 95%.
Results: The results showed 17.4% subjects were categorized depression, 65.2% were anxiety and 34.8% were stress. Statiscally
analyzed using Fisher test showed that there were significantly association between depression with obesity (p=0.003; OR=0.219)
and stress with obesity (p=0.044, OR=0.028). Conclusion: Psychological aspects such as depression and stress were related to
obesity in State Senior High Schools Students in Pekanbaru

KEY WORDS: adolescent; anxiety; depression; obesity; stress

ABSTRAK
Latar belakang: Obesitas dapat terjadi pada berbagai usia, termasuk pada remaja. Berbagai faktor berperan dalam terjadinya obesitas
ini salah satunya faktor psikologi. Jumlah asupan makanan yang berlebihan bisa merupakan respon dari perasaan kesepian, dukacita
atau depresi. Kecemasan juga berkontribusi besar dalam menentukan jumlah asupan makanan dan zat gizi, sedangkan stres dapat
menyebabkan terjadinya perilaku makan yang tidak normal (berlebihan) yang bisa mengarah ke obesitas. Tujuan: Mengetahui
depresi, ansietas dan stres pada remaja di Pekanbaru serta hubungannya dengan obesitas. Metode: Penelitian potong lintang dengan
melibatkan 132 responden yg berasal dari 7 SMA Negeri dari 14 SMA Negeri yang ada di Pekanbaru. Sebanyak 66 responden
memiliki status gizi gemuk/obes dan 66 responden memiliki status gizi kurus/normal. Status gizi ditentukan berdasarkan IMT/U pada
anak usia 5-18 tahun yang ditetapkan Kementrian Kesehatan tahun 2010. Depresi, ansietas dan stres dinilai dengan menggunakan
kuesioner kuesioner depression, anxietas, stress scale 42 (DASS 42) dan dikelompokkan menjadi tidak dan mengalami depresi/
ansietas/stres. Data dianalisis menggunakan uji Chi-Square dengan derajat kepercayaan 95%. Hasil: Sebesar 17,4% responden
mengalami depresi; 65,2% mengalami ansietas; dan 34,8% mengalami stres. Terdapat hubungan bermakna antara depresi dengan
obesitas (p=0,005; OR=0,219) dan stres dengan obesitas (p=0,044; OR=0,443). Simpulan: Faktor psikologi seperti depresi dan
stres berhubungan dengan kejadian obesitas pada remaja di Pekanbaru

KATA KUNCI: remaja; ansietas; depresi; obesitas; stres

PENDAHULUAN
Masalah gizi lebih atau obesitas merupakan salah
satu masalah kesehatan global, yang dikenal dengan
new world syndrome yang dapat menimbulkan berbagai
Korespondensi: Huriatul Masdar, Fakultas Kedokteran Universitas Riau, Jl.
Diponegoro 1 Pekanbaru, Telp. (0761) 839264 ext. 308, Fax. (0761) 839265,
e-mail: huriatul.masdar@lecturer.unri.ac.id

138
 Huriatul Masdar, dkk: Depresi, ansietas, dan stres serta hubungannya dengan obesitas pada remaja
masalah kesehatan, kecacatan maupun masalah finansial
secara global (1,2). Obesitas dapat terjadi baik di negara
maju maupun negara berkembang, semua strata sosial
dan ekonomi serta dapat mengenai berbagai usia.
Dilaporkan sekitar 17% anak dan remaja di Amerika
Serikat mengalami obesitas (1). Di Indonesia, Riset
kesehatan dasar (Riskesdas) tahun 2013 melaporkan
bahwa terjadi peningkatan prevalensi obesitas pada
anak di Indonesia. Pada kelompok anak usia 6-12 tahun
terjadi peningkatan dari 9,2% (tahun 2010) menjadi
18,8% (tahun 2013), pada kelompok anak usia 13-15
tahun terjadi peningkatan dari 2,5% (tahun 2010) menjadi
10,8% (tahun 2013), dan pada kelompok anak usia 16-
18 tahun terjadi peningkatan dari 1,4% pada tahun 2010
menjadi 7,3% pada tahun 2013 (3,4). Hal yang sama
juga terlihat di Provinsi Riau, yaitu pada masing-masing
kelompok usia anak terjadi peningkatan kejadian obesitas
dari tahun 2010 ke tahun 2013 secara berturut-turut
sebesar 10,9% menjadi 18% pada usia 6-12 tahun; 2,2%
menjadi 10% pada usia 13-15 tahun; dan 1,0% menjadi
4,8% pada usia 16-18 tahun (3,4). Penelitian sebelumnya
menunjukkan angka kejadian obesitas pada pelajar SMA
Negri di Kota Pekanbaru sebesarnya 23,5%, yaitu 56%
terjadi pada pelajar perempuan sedangkan 44% pelajar
laki-laki (5).
Peningkatan yang cukup tinggi dari angka kejadian
obesitas pada anak ini sangat mengkhawatirkan dan
berisiko untuk munculnya penyakit-penyakit metabolik
pada usia yang lebih dini. Penelitian di Iran (2013)
menunjukkan sebesar 17,4% anak usia sekolah di
Timur Tengah dan Afrika Utara mengalami obesitas dan
15,4% dari siswa obes tersebut diidentifikasi mengalami
sindroma metabolik (6). Penelitian lain di Amerika (2012)
yang dilakukan pada anak usia 12-19 tahun menunjukkan
8,1% anak mengalami sindroma metabolik (7).
Faktor-faktor yang dapat menyebabkan tingginya
prevalensi obesitas pada anak ini dapat bersifat genetik
maupun lingkungan. Keadaan psikologis anak juga
disebutkan sebagai salah satu pemicu terjadinya obesitas.
Pada orang-orang tertentu, makan berlebihan dapat terjadi
sebagai respon dari suatu perasaan stres, depresi atau
cemas. Hal ini apabila dibiarkan akan beresiko untuk
menjadi obesitas. Hasil penelitian menunjukkan bahwa
semakin tinggi stres yang dialami seseorang, semakin
tinggi pula tingkatan indikator status gizinya. Di sisi
lain, obesitas juga dapat mempengaruhi faktor kejiwaan
seorang anak seperti merasa kurang percaya diri. Hal
ini lebih terlihat pada anak usia remaja, biasanya akan
menjadi pasif dan depresi dan cenderung tidak mampu
bersosialisasi dengan teman sebayanya (8).
Penelitian ini bertujuan untuk melihat hubungan
antara depresi, ansietas. dan stres terhadap kejadian
obesitas pada remaja di Kota Pekanbaru. Penelitian
ini diharapkan bisa mengidentifikasi salah satu faktor
yang berkontribusi terhadap tingginya angka kejadian
obesitas pada remaja di Kota Pekanbaru sehingga dapat
direkomendasikan solusi untuk mengatasi masalah
obesitas pada pelajar ini.
BAHAN DAN METODE
Penelitian ini adalah penelitian potong lintang dan
telah mendapatkan persetujuan etik penelitian dari Unit
Etika Penelitian Kedokteran dan Kesehatan Fakultas
Kedokteran Universitas Riau dengan nomor 103/
UN.19.5.1.1.8/UNPKK/2015. Penelitian dilaksanakan
pada bulan September sampai dengan November
2015. Sebanyak 132 orang responden (66 responden
overweight/obes dan 66 responden normal) dipilih
dengan menggunakan metode multistage purposive
sampling. Responden diambil dari 7 SMA Negeri dari
14 SMA Negeri yang ada di Pekanbaru secara merata,
rentang usia 15-18 tahun, dan memenuhi kriteria
inklusi yaitu menyatakan kesediaan menjadi responden
penelitian, tidak dalam keadaan sakit kronis yang dapat
menyebabkan perubahan berat badan dan tidak sedang
mengonsumsi obat-obatan, herbal, maupun suplemen
yang dapat menaikan atau menurunkan berat badan.
Status gizi responden ditentukan dengan
menggunakan standar antropometri penilaian status gizi
anak yang tertuang dalam Keputusan Menteri Kesehatan
Republik Indonesia nomor 1995 tahun 2010, yaitu
dengan menggunakan indikator antropometri indeks
masa tubuh dibandingkan usia (IMT/U) untuk anak usia
5-18 tahun. Pengukuran berat badan dilakukan dengan
menggunakan timbangan injak. Pengukuran dilakukan
dua kali per responden dan diukur hingga satu angka
desimal. Pengukuran tinggi badan dilakukan dengan
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Jurnal Gizi Klinik Indonesia, Vol. 12, No. 4, April 2016: 138-143

menggunakan microtoise. Pengukuran dilakukan dua HASIL

kali pada masing-masing repsonden dan dinilai hingga
Penelitian ini melibatkan 132 responden yang
satu angka desimal. Penetapan status gizi dilakukan
diambil secara multistage purposive sampling, yang
dengan menggunakan WHO-anthroplus v1.0.4 software.
terdiri dari 66 orang responden memiliki status gizi
Responden dengan status gizi gemuk dan obesitas
dengan kategori gemuk/obes dan 66 orang memiliki
(z-score> +1SD) dikategorikan sebagai kelompok obes
status nutrisi kurus/normal sesuai kriteria yang ditetapkan
dan responden dengan status nutrisi sangat kurus, kurus,
oleh Kementrian Kesehatan pada tahun 2010. Responden
dan normal (z-score ≤+1SD) dikategorikan sebagai
berusia sekitar 15-18 tahun dengan rerata usia 16,28
kelompok non-obes.
tahun dan jenis kelamin laki-laki dan perempuan masing-
Depresi, ansietas dan stres dinilai dengan
masingnya sebanyak 50%, baik pada kelompok obes
menggunakan kuesioner Depression, Anxietas, Stress
maupun non-obes.
Scale 42 (DASS 42) yang dikeluarkan oleh Psychology
Hasil pemeriksaan psikologi responden dengan
Foundation Australia. Kuesioner yang digunakan adalah
menggunakan DASS 42 menunjukkan bahwa sebanyak
DASS 42 versi translasi ke bahasa Indonesia oleh
17,4% responden mengalami depresi. Depresi ini lebih
Damanik E (9). Pada kuesioner ini terdapat masing-
banyak ditemukan pada responden perempuan (21,2%)
masing 14 pertanyaan untuk menilai adanya depresi,
dibandingkan lak-laki (13,4%). Lebih lanjut, responden
ansietas dan stres. Masing-masing pertanyaan memiliki
yang mengalami ansietas dan stres diperoleh masing-
skor 0-3. Total skor ≤9, ≤7, dan ≤14 secara berturut
masing sebesar 65,2% dan 34,8% secara berturut-turut.
untuk masing-masing kategori depresi, ansietas maupun
Sama halnya dengan depresi, responden wanita terlihat
stres dinyatakan sebagai tidak depresi/ansietas/stres, dan
lebih banyak mengalami ansietas dan stres dibandingkan
sebaliknya skor diatas 9, 7, dan 14 dinyatakan mengalami
laki-laki. Tidak terdapat hubungan yang bermakna antara
depresi, ansietas atau stres tanpa membedakan derajatnya.
jenis kelamin responden dengan depresi, ansietas maupun
Hubungan depresi, stres, dan ansietas dengan status
stres yang dialami (Tabel 1 dan 2).
gizi diuji secara statistik dengan menggunakan uji Chi-
Berdasarkan status gizinya, responden dengan
Square.
status gizi tergolong obes sekitar 7,6% mengalami
depresi. Persentase ini lebih rendah dibandingkan
Tabel 1. Gambaran depresi, ansietas, dan stres pada
responden yang terkategori non-obes yaitu 27,3% dari
remaja di Pekanbaru (n=132) responden yang tergolong non-obes mengalami depresi.
Jumlah Hasil analisis secara statistik dengan menggunakan
Variabel Kategori
n % uji Chi-Square menunjukkan adanya hubungan antara
Depresi Tidak depresi (skor ≤9) 109 82,6 depresi dengan status gizi responden (p=0,003) yaitu
Depresi (skor >9) 23 17,4
remaja yang mengalami depresi akan menjadi obes 0,219
Ansietas Tidak ansietas (skor ≤7) 46 34,8
Ansietas (skor >7) 86 65,2 kali dibandingkan remaja yang tidak obes. Ansietas
Stres Tidak stres (skor ≤14) 86 65,2 ditemukan pada 60,6% responden yang terkategori obes
Stres (skor >14) 46 34,8 dan 69,7% pada responden dengan kategori non-obes,

Tabel 2. Gambaran depresi, ansietas, dan stres berdasarkan jenis kelamin pada remaja di Pekanbaru (n=132)
Laki-laki Perempuan
Variabel Kategori p OR (IK 95%)
n % n %
Tidak depresi (skor ≤9) 57 86,7 52 78,8 0,251 1,705
Depresi
Depresi (skor >9) 9 13,6 14 21,2 (0,681-4,27)
Tidak ansietas (skor ≤7) 28 42,4 18 27,3 0,068 1,965
Ansietas
Ansietas (skor >7) 38 47,6 48 72,7 (0,948-4,074)
Tidak stres (skor ≤14) 47 71,2 39 59,0 0,144 1,713
Stres
Stres (skor >14) 19 28,8 27 41,0 (0,830-3,534)

140
 Huriatul Masdar, dkk: Depresi, ansietas, dan stres serta hubungannya dengan obesitas pada remaja
Tabel 3. Gambaran depresi, ansietas, dan stres berdasarkan status nutrisi pada remaja di Pekanbaru (n=132)
Status gizi
Kategori Non obes
n %
Tidak depresi (skor ≤9) 48 72,7
Depresi
Depresi (skor >9) 18 27,3
Tidak ansietas (skor ≤7) 20 30,3
Ansietas
Ansietas (skor >7) 46 69,7
Tidak stres (skor ≤14) 37 56
Stres
Stres (skor >14) 29 44
* bermakna secara statistic (p<0,05)
serta tidak terdapat hubungan antara ansietas dengan
status gizi responden (p=0,273). Parameter psikologi
lain yaitu stres ditemukan sebesar 25,8% pada responden
terkategori obes dan 44,0% pada responden yang tidak
terkategori obes dan terdapat hubungan yang bermakna
secara statistik antara stres dan status gizi responden
(p=0,028; OR=0,443 (Tabel 3).
BAHASAN
Gangguan psikologi baik itu depresi, ansietas
maupun stres diduga menjadi salah satu faktor risiko
terjadinya obesitas baik pada usia kanak-kanak maupun
maupun muncul setelah usia dewasa (10). Berbagai
bentuk stresor dapat memicu terjadinya depresi, ansietas,
dan stres pada anak usia sekolah. Hal ini dapat berupa
stresor yang berasal dari keluarga, lingkungan sekolah,
baik itu stresor dari kegiatan akademik, guru maupun
teman-teman sekolahnya (8).
Dalam penelitian ini ditemukan sebesar 17,4%
remaja di Pekanbaru mengalami depresi dan ditemukan
bahwa perempuan lebih banyak mengalami depresi
dibandingkan laki-laki. Depresi lebih cenderung banyak
dialami oleh perempuan dibandingkan laki-laki dapat
disebabkan oleh beberapa faktor diantaranya yaitu
perempuan kurang asertif dan cenderung memiliki skor
yang lebih rendah dalam hal kemampuan kepemimpinan
daripada anak laki-laki, anak perempuan lebih sering
menggunakan coping ruminatif dibanding anak laki-laki
yaitu perempuan lebih memusatkan perhatiannya pada
simptom-simptom depresi yang dialaminya. Sebaliknya,
anak laki-laki cenderung mengalihkannya pada beberapa
aktivitas fisik seperti menonton televisi, berperilaku
agresif. Di samping itu, anak perempuan kurang dominan,
OR
Obes p
(IK 95%)
n %
61 92,4 0,219
0,003*
5 7,6 (0,076-0,631)
26 39,4 0,669
0,273
40 60,6 (0,325-1,375)
49 74,2 0,443
0,028*
17 25,8 (0,212-0,923)
kurang agresif baik secara fisik maupun verbal dalam
berinteraksi dengan kelompoknya (11).
Kecemasan atau ansietas merupakan bentuk
gangguan psikologi yang cukup banyak ditemukan pada
remaja di Pekanbaru (65,2%). Penelitian yang dilakukan
pada pelajar salah satu SMA Negeri di Surakarta juga
menunjukkan hasil yang sama yaitu sebanyak 60%
responden mengalami gangguan kecemasan atau
ansietas (12). Gangguan cemas merupakan gangguan
yang banyak terjadi pada anak dan remaja. Gangguan
kecemasan ini biasanya timbul karena perkembangan
tidak tepat serta kekhawatiran yang berlebihan. Jenis
kecemasan pada remaja dan anak usia sekolah secara
signifikan dapat mengganggu kegiatan harian dan
tugas-tugas perkembangan. Dalam penelitian ini, pelajar
perempuan yang mengalami ansietas lebih banyak
dibandingkan pelajar laki-laki. Hal ini juga sejalan
dengan penelitian sebelumnya bahwa remaja dengan
jenis kelamin perempuan lebih banyak yang mengalami
kecemasan dibandingkan laki-laki (12). Jenis kelamin
kadang berpengaruh dalam menentukan pertahanan diri
seseorang terhadap kecemasan. Fobia sosial lebih banyak
ditemukan pada laki-laki sedangkan pada fobia yang
sederhana gangguan menghindar dan agoraphobia lebih
banyak ditemukan pada remaja perempuan. Sementara
cemas perpisahan, gangguan cemas menyeluruh, dan
gangguan panik didapatkan pada kedua jenis kelamin
(13).
Lebih lanjut, gangguan stres pada penelitian ini
ditemukan juga lebih banyak pada pelajar perempuan
(41,0%) dibandingkan laki-laki (28,8%). Penyebab
stres pada remaja dapat dipicu dari kematian orang yang
dicintai atau menyaksikan peristiwa yang traumatis,
penyebab yang paling umum berhubungan dengan
141
Jurnal Gizi Klinik Indonesia, Vol. 12, No. 4, April 2016: 138-143
sekolah (seperti intimidasi dari teman-teman, masalah
dengan guru, dan kesulitan akademis) dan hubungan
interpersonal (seperti konflik dengan orang tua, saudara,
dan teman sebaya) (14,15). Sumber stres pada remaja
laki-laki dan perempuan pada umumnya sama, hanya
saja remaja perempuan sering merasa cemas ketika
sedang menghadapi masalah sedangkan pada remaja
laki-laki cenderung lebih berperilaku agresif. Remaja
laki-laki yang mengalami stres akan melakukan perbuatan
negatif seperti mengonsumsi rokok dan alkohol (13).
Kemungkinan faktor tersebutlah yang menyebabkan
stres pada perempuan lebih banyak jika dibandingkan
dengan laki-laki.
Hasil analisis menunjukkan adanya hubungan
yang bermakna secara statistik antara depresi dan stres
dengan status gizi responden (p=0,003). Penelitian
yang dilakukan di Minnesota terhadap 553 remaja
dengan obesitas menunjukkan hal yang serupa, yaitu
depresi yang dialami oleh responden dengan obesitas
tersebut berhubungan dengan status gizinya. Adanya
ketidakpercayaan diri yang dialami oleh remaja dengan
obesitas akan pencitraan tubuhnya membuat mereka
cenderung menarik diri dan menjadi depresi (15).
Penelitian ini didukung hasil penelitian pada mahasiswa
Fakultas Kedokteran Univeristas Lampung yang juga
menemukan hal sama yaitu depresi memiliki hubungan
yang bermakna dengan obesitas (16). Depresi merupakan
salah satu faktor risiko terjadinya status gizi lebih dan
status gizi kurang dan sebaliknya keadaan status gizi juga
dapat menimbulkan depresi pada seseorang.
Hasil penelitian yang dilakukan di SMU
Methodist-8 Medan juga menunjukkan adanya hubungan
yang signifikan antara stres dengan status gizi, yaitu
semakin tinggi skor stres seseorang semakin tinggi
tingkatan status gizinya. Siswa yang memiliki status gizi
gemuk dan obesitas mengalami stres sedang dan stres
berat (17). Hal ini sejalan dengan hasil penelitian ini
bahwa stres mempengaruhi kebiasaan makan seseorang,
yaitu orang cenderung mencari makanan berkalori tinggi
dan tinggi lemak selama periode stres. Berdasarkan survei
yang dilakukan oleh American Psychology Association
tahun 2013, sebesar 37% dari remaja yang makan
berlebihan atau makan makanan yang tidak sehat karena
stres menyatakan bahwa hal tersebut adalah kebiasaan.
142
Sementara sebesar 33% remaja menyatakan mereka
melakukannya karena membantu mengalihkan perhatian
mereka dari apa yang menyebabkan mereka stres dan
hampir seperempat dari remaja melaporkan makan untuk
mengelola stres (18).
Saat tubuh kita mengalami stres yang merupakan
suatu ancaman dalam diri kita, seperti orang yang
takut kegemukan, yang selalu mengkhawatirkan berat
badannya, justru memicu kelenjar adrenal melepaskan
kortisol lebih banyak sebagai respon alami tubuh terhadap
stres. Tingginya kadar hormon kortisol akan merangsang
tubuh untuk mengeluarkan hormon insulin, leptin, dan
sistem neuropeptide Y (NPY) yang akan membuat otak
membangkitkan rasa lapar sehingga timbul keinginan
makan, pemilihan jenis makanan tinggi gula dan lemak,
serta menimbulkan motivasi untuk mencari makanan
berkalori tinggi yang menenangkan dan menyimpan
kalori ekstra sebagai lemak di bagian perut (19).
Pada penelitian ini tidak menunjukkan adanya
hubungan bermakna antara ansietas dengan kejadian
obesitas (p=0,273). Hasil penelitian tidak sesuai dengan
teori yang mengatakan bahwa kecemasan memiliki
kontribusi yang besar dalam menentukan asupan makan
dan zat gizi. Namun, perlu disadari bahwa penyebab
terjadinya obesitas tidak hanya faktor psikologi. Jumlah
asupan zat gizi dan aktivitas fisik juga merupakan
faktor risiko yang berkontribusi besar terhadap kejadian
obesitas.
SIMPULAN DAN SARAN
Faktor psikologi seperti depresi dan stres memiliki
hubungan yang bermakna dengan status gizi pada remaja
di Pekanbaru dan sebaliknya ansietas tidak memiliki
hubungan yang bermakna dengan status gizi pada remaja
di Pekanbaru. Faktor psikologi ini hanya merupakan
salah satu faktor risiko pemicu terjadinya obesitas pada
anak usia sekolah sehingga masih perlu diteliti lebih
lanjut faktor-faktor risiko lain yang dapat menyebabkan
tingginya angka kejadian obesitas pada remaja di
Pekanbaru. Dengan demikian, diharapkan angka kejadian
obesitas pada anak usia sekolah dapat ditekan dan risiko
munculnya gangguan akibat obesitas pada usia dini itu
dapat dicegah.
 Huriatul Masdar, dkk: Depresi, ansietas, dan stres serta hubungannya dengan obesitas pada remaja

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Rahman et al. BMC Pediatrics (2018) 18:311
https://doi.org/10.1186/s12887-018-1283-8

RESEARCH ARTICLE Open Access

How often parents make decisions with

their children is associated with obesity
Adrita Rahman1, Kimberly G. Fulda2,3* , Susan F. Franks2,3, Shane I. Fernando2,4, Nusrath Habiba4
and Omair Muzaffar2,3

Abstract
Background: Evidence supports that better parental involvement and communication are related to reduced
obesity in children. Parent-child collaborative decision-making is associated with lower BMI among children; while
child-unilateral and parent-unilateral decision-making are associated with overweight children. However, little is
known about associations between joint decision-making and obesity among Hispanic youth. The purpose of this
analysis was to determine the relationship between parent-child decision making and obesity in a sample of
predominantly Hispanic adolescents.
Methods: Data from two studies focused on risk for type II diabetes were analyzed. A total of 298
adolescents 10–14 years of age and their parent/legal guardian were included. Parents completed
questionnaires related to psychosocial, family functioning, and environmental factors. Multiple logistic
regression was used to determine the association between obesity (≥ 95th percentile for age and gender),
the dependent variable, and how often the parent felt they made decisions together with their child
(rarely/never, sometimes, usually, always), the primary independent variable. Covariates included gender, age,
ethnicity, total family income, and days participated in a physical activity for at least 20 min. ORs and 95%
CIs were calculated.
Results: Adolescent participants were predominantly Hispanic n = 233 (78.2%), and approximately half n =
150 (50.3%) were female. In multivariate analyses, adolescents who rarely/never made decisions together
with their family had significantly higher odds (OR = 3.50; 95% CI [1.25–9.83]) of being obese than those
who always did. No association was observed between either those who sometimes make decisions
together or those who usually did and those that always did.
Conclusions: Parents and children not making decisions together, an essential aspect of parent-child
communication, is associated with increased childhood obesity. The results of our study contribute to
evidence of parental involvement in decision-making as an important determinant of adolescent health.
Further studies should explore temporal relationships between parenting or communication style and
obesity.
Keywords: Obesity, Adolescent – Parent communication, Decision making between parents and adolescents

* Correspondence: kimberly.fulda@unthsc.edu
2
North Texas Primary Care Practice-Based Research Network (NorTex),
University of North Texas Health Science Center at Fort Worth, 3500 Camp
Bowie Blvd, Fort Worth, TX 76107, USA
3
Department of Family Medicine, Texas College of Osteopathic Medicine,
University of North Texas Health Science Center at Fort Worth, 3500 Camp
Bowie Blvd, Fort Worth, TX 76107, USA
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Rahman et al. BMC Pediatrics (2018) 18:311
Background
Disparities between Hispanic and non-Hispanic popula-
tions in the area of childhood and adolescent obesity are
critically important to understand, as these may predict
related health disparities that can continue throughout
life [1–4]. In 2015-2016, 25.8% of Hispanic youth were
obese, compared to 22.0% of non-Hispanic black youth
and 14.1% of non-Hispanc white youth [5]. Studies have
shown that, similar to other ethnic groups [6], the rise in
obesity among Hispanic youth is multifactorial involving
a combination of genetic factors [7] and environmental
factors [1], which include parental influence [8].
Lack of parental involvement and communication have
consistently been highly related to obesity in children
and adolescents [9–14]. Healthy family functioning,
which consists of good communication, problem solving,
roles, affective responsiveness, affective involvement,
and behavioral control, is associated with more frequent
family meals, greater daily vegetable and fruit consump-
tion, more frequent breakfast consumption, fewer hours
of sedentary behavior, lower BMI and lower percent
overweight in adolescent girls [9]. Greater communica-
tion between parents and children also promotes health-
ier nutritional habits, lower weight and greater physical
activity [10–12]. Furthermore, shared parent-child activ-
ities have been associated with less overweight and obes-
ity [13]. One study found that children who made more
decisions themselves, especially regarding nutrition, were
more likely to be obese [14]. Parent-child collaborative
decision-making is associated with better health behav-
iors, including healthy eating behaviors [15].
Unhealthy nutritional habits, physical inactivity, and be-
ing overweight or obese are all well-established modifiable
risk factors for type II diabetes [16]. Also, having the per-
ception of insufficient parental care and inadequate paren-
tal communication has been linked to higher risk for
mental and behavioral problems, including unhealthy
weight control habits among adolescents [17]. Lower ma-
ternal sensitivity is associated with adolescent obesity [18],
and poor maternal-child relationships at the ages of 15, 24
and 36 months of age is associated with higher adolescent
obesity [19]. Having good communication with parents,
therefore, may be a protective factor for obesity and type
II diabetes among adolescents.
Children whose parents talk to them about weight loss
and restrict their eating practices are more likely to en-
gage in unhealthy and disordered eating habits and gain
weight, while those whose parents discuss healthy eating
are less likely to eat unhealthy [20–23]. Parents using
more lax and coercive disciplinary strategies, fewer
health promoting techniques, and possessing less confi-
dence in child lifestyle behavior management are more
likely to have obese children [24]. In summation, an au-
thoritative parenting style, where decision-making is
Page 2 of 8
collaborative, is associated with lower BMI among chil-
dren and adolescents [25, 26], while more permissive/in-
dulgent and rejecting/uninvolved parenting styles, where
decision-making is child-unilateral, and authoritarian
parenting and feeding styles, where decision-making is
parent-unilateral, are associated with overweight chil-
dren [8, 27–30].
Restriction of dietary intake is more common among par-
ents who are racial or ethnic minorities, have low income,
and have less than a high school education [31]. However,
little is known about associations between parent-child com-
munication and obesity among Hispanic youth. Studies have
shown that Mexican-American adolescents have greater re-
spect for parental authority and interdependence and less
personal autonomy and independence, indicating less
child-unilateral decision making, compared to white Ameri-
can adolescents [32–36]. For instance, Mexican mothers of
young teenage daughters expect increases in parent-child
mutual decision-making after their daughters turn 15 years
old, a delayed age compared to other ethnic groups in the
U.S. [36] Furthermore, Mexican-American mothers of very
young children are the primary decision-makers when it
comes to behaviors related to obesity, including sleep, phys-
ical activity and television screen time, although parents and
children sometimes or often make decisions together re-
garding nutrition [37]. There is, however, a lack of a
complete understanding of the determinants of the dispar-
ities in obesity. For example, participants in focus groups
with low-income Hispanic mothers said their children liked
fast food, and they placed no restrictions on the food their
child wanted and decided to eat [38]. In another study, His-
panic parents said they allowed their child to decide what to
eat as alternatives, and pressured them to eat more food
[39]. We hypothesized that parent-child cooperative decision
making as reported by the parent is associated with child-
hood obesity in Hispanic and non-Hispanic adolescents.
Methods
Study design
The association between parent-child decision making and
obesity was explored using data from two cross-sectional
studies focused on risk for type II diabetes and adoles-
cence. These studies were titled “Factors Associated with
Being at Risk for Type 2 Diabetes among Mexican and
Mexican-American Children” (DMMX) and “Psychosocial
and Physiological Predictors of Type 2 Diabetes Mellitus
among Children Aged 10-14” (PedDM). Data were col-
lected from 298 participants in Tarrant County, Texas be-
tween both study protocols. Subjects included adolescents
(age 10 to 14 years, male or female, English or Spanish
speaking) with a parent or legal guardian. The DMMX
study only included Mexican (recruited at a partner institu-
tion in Mexico) or Mexican-American (recruited locally in
the US) adolescents; whereas, the PedDM study included
Rahman et al. BMC Pediatrics (2018) 18:311
all race/ethnicities (recruited in the US). Only the Mexican
American child participants from the DMMX study were
included in the current analysis. The participants recruited
in Mexico were not included in this analysis. Identical
methods were used for both studies, and participants were
recruited from the same geographical area, which allows
for combining the data to have a larger sample size. Both
studies included nondiabetic child participants. Exclusion
criteria from the original studies consisted of having cystic
fibrosis, diabetes mellitus, genetic syndromes, hypo- or
hyperthyroidism, adrenal disease (Addison’s or Cushing
syndrome), taking oral corticosteroids (prednisone, pred-
nisolone, orapred, decadron, dexamethasone) during the
past year, or inability to provide consent. Parental consent
and child assent were obtained since adolescent subjects
were minors. Study procedures included one encounter at
the University of North Texas Health Science Center
(UNTHSC) that lasted about two hours. Parents com-
pleted surveys related to psychosocial, family functioning,
and environmental factors. Survey questions were obtained
from the National Survey of Children’s Health 2012.
Demographic information, such as gender, date of birth,
race/ethnicity, socioeconomic status and household size
were also obtained. Study materials were available in Eng-
lish and Spanish.
Study methodologies were approved by the Institu-
tional Review Board of UNTHSC at Fort Worth, Texas.
Dependent variables
The primary dependent variable for this analysis is obes-
ity, a categorical variable. Adolescent participants were
classified as obese and non-obese. Body mass index
(BMI) was calculated, and participants were categorized
into BMI percentiles based on age and gender, according
to CDC guidelines [40]. Those who were at the 95th per-
centile or above were classified as “obese”, and those
under the 95th percentile were classified as “non-obese”
[41]. BMI was used instead of other measures of obesity
since it is routinely collected in a clinic setting.
Primary independent variables
Parents/legal guardians were asked the question “How
often do you feel that your child and you make decisions
about his/her life together?” The responses were re-
corded in a Likert scale as “never,” “rarely”, “sometimes”,
“usually” and “always.” The five categories were con-
densed into four categories; “rarely or never,” “some-
times”, “usually” and “always”. “Rarely” and “never” were
combined because there were very few people in the
“never” category. This question is used by the Centers of
Disease Control and Prevention in the National Survey
of Children’s Health, 2007 and the National Survey of
Adoptive Parents to assess the subdomain Parent/Child
Relationship under Family Functioning [42].
Page 3 of 8
Covariates
Potential covariates in the current analysis included gen-
der, age, ethnicity (Hispanic, non-Hispanic), total family
income per year (less than $10,000, $10,000 to 19,999,
$20,000 to $29,999, $30,000 to $39,999, $40,000 or
more), and days participated in a physical activity for at
least 20 min (less than 7 days, 7 days, I don’t know). The
category “I don’t know” was included because the associ-
ation between the lack of parent’s knowledge regarding
their child’s physical activities and the child’s BMI
needed to be examined as well as lack of physical activ-
ity. It was perceived as representative of the parent’s lack
of involvement in the child’s daily activities.
Statistical analysis
All analyses were conducted using SPSS software version
22 [43]. Descriptive statistics such as means and fre-
quencies are provided for all variables and for levels of
the dependent variable BMI (95th percentile or greater
and less than the 95th percentile). Independent samples
T-tests were used to assess differences between obese
and non-obese participants for the continuous variable
age, and chi-square tests were used to assess differences
in categorical variables between levels of obesity. Simple
and multiple logistic regression models were employed
to examine associations between obesity and independ-
ent variables. Crude and adjusted odds ratios and 95%
confidence intervals were estimated. Missing data were
excluded from the analysis. Only 2% of cases had miss-
ing data. Multi-collinearity between independent vari-
ables was tested using Tolerance and Variation Inflation
Factor (VIF). Results of the multicollinearity tests
showed that collinearity between the variables was very
low, with VIF values ranging from 1.005 to 1.023 and
Tolerance values between 0.995 and 0.977.
Results
Table 1 presents the characteristics of the adolescent
participants by presence of obesity (BMI equal to or
greater than 95th percentile). A total of 298 adolescent
participants were included. After missing data were ex-
cluded, 292 participants were included in the final multi-
variate analysis. The adolescent participants were
predominantly Hispanic (78.2%) with an average age of
11.9 (SD = 1.4) years. Distribution of gender was essen-
tially equivalent with 50.3% girls. Of participants, 80.5%
of parents/guardians reported that they usually or always
made decisions with their child. Only 14.9% of adoles-
cents exercised for at least 20 min all seven days of the
weeks. One hundred and forty (47.8%) reported a total
household yearly income of less than $20,000. Total
household income (p = 0.04) significantly differed be-
tween obese and non-obese adolescents. A majority of
youth (52.8%) who live in households with an income of
Rahman et al. BMC Pediatrics (2018) 18:311 Page 4 of 8

Table 1 Characteristics of the Mexican and Mexican-American Children Study participants by BMI ≥ 95th percentile - Fort Worth,
Texas, (N = 298)
Variable Total number (%) of BMI ≥ 95th percentile, BMI <95th percentile, p-value
participants for category n (%) n (%)
How often parents make decisions together with child n = 298 0.15
Rarely or never 20 (6.7) 12 (60.0) 8 (40.0)
Sometimes 38 (12.8) 14 (36.8) 24 (63.2)
Usually 117 (39.3) 51 (43.6) 66 (56.4)
Always 123 (41.3) 41 (33.3) 82 (66.7)
Age, mean (SD) n = 298 0.57
11.87 (1.405) 11.81 (1.5) 11.90 (1.4)
Sex n = 298 0.74
Male 148 (49.7) 60 (40.5) 88 (59.5)
Female 150 (50.3) 58 (38.7) 92 (61.3)
Ethnicity n = 298 0.17
Hispanic 233 (78.2) 97 (41.6) 136 (58.4)
Non-Hispanic 65 (21.8) 21 (32.3) 44 (67.7)
Days of physical activity for at least 20 min n = 296 0.16
7 days 44 (14.9) 12 (27.3) 32 (72.7)
Less than 7 days 211 (71.3) 90 (42.7) 121 (57.3)
I don’t know 41 (13.9) 16 (39.0) 25 (61.0)
Household income n = 293 0.04
Less than $10,000 53 (18.1) 28 (52.8) 25 (47.2)
$10,000 to $19,999 87 (29.7) 30 (34.5) 57 (65.5)
$20,000 to $29,999 59 (20.1) 23 (39.0) 36 (61.0)
$30,000 to $39,999 40 (13.7) 21 (52.5) 19 (47.5)
$40,000 or more 54 (18.4) 16 (29.6) 38 (70.47)
SD standard deviation

less than $10,000 were obese, compared to a small pro-
portion of obese youth (29.6%) who lived in households
with incomes of $40,000 and above.
Results of simple logistic regression are shown in Table 2.
In bivariate analyses, parent-child decision-making and
household income are both significant predictors of obesity.
How often youth were reported to make decisions with their
parents was significantly associated with obesity. Youth
whose parents reported they rarely or never made decisions
together were (OR = 3.000; 95% CI [1.137–7.914] more likely
to be obese compared to youth whose parents reported they
always made decisions together. Additionally, of the covari-
ates, adolescents in households with a total income of less
than $10,000 (OR = 2.660; 95% CI [1.201–5.890]) or with a
total income of $30,000 to $39,999 (OR = 2.625; 95% CI
[1.119–6.155]) were more likely to be obese than those in
households with a total income of $40,000 or more.
Table 3 displays the results of a multiple logistic regres-
sion model with obesity as the dependent variable and all
other variables as predictors. Adjusting for all other vari-
ables, youth whose parents report they rarely or never
make decisions together with their parents had signifi-
cantly higher odds (OR = 3.501; 95% CI [1.247–9.829]) of
being obese than those who were reported as always mak-
ing decisions with their parents. Of the covariates, age,
gender, physical activity, and ethnicity had no association
with obesity, while household income did. Adolescents liv-
ing in very low-income households of less than $10,000
(OR = 3.329; 95% CI [1.439–7.703]) and from household
incomes between $30,000 and $39,999 (OR = 2.698; 95%
CI [1.117–6.515]) had a greater odds of being obese than
those who came from families with a household income of
$40,000 or greater income even though there were no sig-
nificant differences between the middle income groups
and the highest income group.
Discussion
Parents and children not making decisions together,
an essential aspect of parent-child communication, is
associated with increased childhood obesity. The re-
sults of the present study contribute to evidence of
parental involvement in decision-making as an
Rahman et al. BMC Pediatrics (2018) 18:311 Page 5 of 8

Table 2 Simple logistic regression for BMI ≥ 95th percentile Table 3 Multiple logistic regression for BMI ≥ 95th percentile
with crude odds ratios with adjusted odds ratios
Variable Crude OR 95% CI Variable Adjusted OR 95% CI
How often parents make decisions together with child How often parents make decisions together with child
Always … … Always … …
Rarely or never 3.000 (1.137–7.914) Rarely or never 3.501 (1.247–9.829)
Sometimes 1.167 (0.547–2.490) Sometimes 1.136 (0.511–2.527)
Usually 1.545 (0.916–2.609) Usually 1.639 (0.940–2.855)
Age 0.957 (0.811 - 1.129) Age 0.956 (0.800 - 1.144)
Sex Sex
Female … … Female … …
Male 1.082 (0.680–1.721) Male 1.095 (0.669–1.792)
Household Income Household Income
$40,000 or more … … $40,000 or more … …
Less than $10,000 2.660 (1.201–5.890) Less than $10,000 3.329 (1.439–7.703)
$10,000 to $19,999 1.250 (0.601–2.600) $10,000 to $19,999 1.170 (0.551–2.486)
$20,000 to $29,999 1.517 (0.693–3.324) $20,000 to $29,999 1.537 (0.687–3.438)
$30,000 to $39,999″ 2.625 (1.119–6.155) $30,000 to $39,999 2.698 (1.117–6.515)
Ethnicity Ethnicity
Non-Hispanic … … Non-Hispanic … …
Hispanic 1.494 (0.836–2.673) Hispanic 1.636 (0.862–3.104)
Days of physical activity for at least 20 min Days of physical activity for at least 20 min
7 days … … 7 days … …
Less than 7 days vs 7 days 1.983 (0.968–4.064) less than 7 days vs 7 days 2.109 (0.981–4.536)
I don’t know vs 7 days 1.707 (0.685–4.253) I don’t know vs 7 days 2.266 (0.852–6.025)
… = reference group, OR odds ratio, 95% CI 95% confidence interval … = reference group; OR odds ratio, 95% CI 95% confidence interval

important determinant of adolescent health. In this
study, youth whose parents reported they rarely or
never made decisions with their parents were more
likely to have a BMI in the 95th percentile or above
compared to those who always made decisions with
their parents. The results complement the findings of
studies that support relationships between better
parent-child communication and reduced child obesity
[8, 28–30, 44].
The significant association found in this study between
BMI and how often children are reported as making de-
cisions together with their parents complements the lit-
erature. How often adolescents make their life decisions
with their parents may be representative of how involved
the parents are in their children’s lives, and also how
close the parent-child relationship is in terms of com-
munication and trust. Greater parental involvement may
lead to children making fewer negative choices, includ-
ing those regarding their nutritional and lifestyle habits.
Better nutritional and lifestyle choices may in turn make
them less likely to be obese compared to peers who
make unhealthy decisions. Unhealthy nutritional habits
include eating disorders, which are associated with
perception of low parental caring, poor parent-child
communication, and valuing peers’ opinions over par-
ents’ [17]. Therefore, in accordance with previous find-
ings on communication and obesity, adolescents whose
parents report rarely make decisions with their families
are more likely to be obese.
Interestingly, age does not appear to be a good
predictor of obesity in this sample, even though in
2011–2014, there were disparities in obesity prevalence
between the age groups of 2 to 5 years, 6 to 11 years
and 12 to 19 years [5]. However, the range of our sample
is only between the years of 10 and 14 years. Perhaps ex-
ploring these associations in a cohort consisting of a
wider age range might show different results. Further-
more, the current study did not find gender to be a pre-
dictor of high BMI, and there was no statistically
significant difference in obesity between Hispanics and
non-Hispanics. Being physically active for at least
20 min every day of the week is not associated with de-
creased obesity in this population, although research
shows that physical activity is associated with reduced
overweight and obesity among youth [45]. The CDC,
however, recommends 60 min of exercise every day for
Rahman et al. BMC Pediatrics (2018) 18:311
7 days [46], so perhaps the children in this study were
not getting sufficient exercise. A relationship between
household annual income of less than $10,000 and pres-
ence of obesity is also consistent with the literature, as
low socioeconomic status is associated with child obes-
ity. The finding that families earning between $30,000
and $39,999 are more likely to have children with obes-
ity needs further exploration. Results of one study
showed that among Mexican-origin families, fathers re-
ported more joint parent-child decision making when
they were of high SES, and mothers reported less
child-unilateral decision-making when they were of high
SES [47]. Despite controlling for the effects of household
income, however, a statistically significant association
between parent-child decision-making and child obesity
remained in our study.
Strengths
One of the strengths of this study is that weight and
height were measured and not self-reported by the sub-
jects. Some studies use self-reported weight and height as
opposed to measured weight and height [44, 48]. Al-
though overall self-reported height and weight are posi-
tively associated with measured height and weight,
females and obese children are statistically more likely to
under-report their weight, and children who are shorter
than 150 cm are more likely to under-report their height
[48]. The BMI percentiles are based on those objective
measurements, and the study used the online CDC calcu-
lator with age and sex of the child.
Limitations
A limitation of this study is its cross-sectional nature. This
prevents inferring causation between parent-child decision
making and child obesity status. Another limitation is that
only one component of parent-child decision making is
assessed in this study. Additionally, parent-child decision
making was measured using a single item. This item has
been used by the CDC to measure family functioning in
national surveys; however, future research should include
a more robust measure. Information about parental obes-
ity, which is positively associated with childhood obesity
[49–54], is also not available for this study. The number of
children above a BMI percentile of 95 who were reported
to have rarely or never made decisions with their parents
was also small, leading to wide confidence intervals in our
model. Studies should explore this further by recruiting a
larger sample of parents who rarely report joint
decision-making with their children.
Conclusions
Future studies should explore temporal or dyadic rela-
tionships between parenting or communication style and
obesity. Further investigations should explore these
Page 6 of 8
associations using causal inference. A longitudinal study
would be able to examine these relationships temporally.
Those that used self-reported BMI [46] were done in
young children, were done in samples not representative
of the US youth population [55], or only used maternal
relationships [56]. Many cross-sectional studies have
been done, but few have been done on how parent-child
relationships predict obesity and other cardio-metabolic
outcomes later in adulthood. Thus, longitudinal studies
should also include cardio-metabolic biological markers
in addition to weight and behavioral outcomes.
Additional studies should also include children from
different ethnic and cultural backgrounds, as cultural
backgrounds could influence relationships between
parent-child decision making and obesity in children.
For example, a study conducted on Chinese-American
youth showed that authoritarian parenting style was as-
sociated with lower child obesity, contradictory to stud-
ies done on American populations, likely because of
greater parental authority and child obedience in Chin-
ese culture compared to American culture [57]. There-
fore similar studies should also be conducted with other
ethnic populations to see how decision-making is related
to weight-related practices and weight status.
Evidence shows that eating behavior can be influenced
by sibling behavior [58], and that having an obese sibling
increases the likelihood of child obesity [51]. However,
most studies investigating parent-child decision making
and child weight do not look at sibling relationships,
and many that do look at siblings are genetic studies.
Therefore, future studies should include relationships
between siblings as a potential confounder. One of the
limitations was that only one aspect of parent-child
communication was explored. Other aspects of commu-
nication in relation to obesity status need to be studied.
Different developmental ages should be included, as ad-
olescents give more value to their own opinions for
making decisions and gradually spend less time with
their parents as they grow older [59]. Increasing the age
range may help determine when decision-making comes
into play and how it affects weight and nutritional health
in youth.
Abbreviations
95% CI: 95% confidence interval; OR: Odds ratio
Acknowledgements
We would like to acknowledge the research staff of the North Texas Primary
Care Practice-Based Research Network (NorTex) for their help in processing
research participants.
Funding
This research was funded through an intramural grant program at the UNT
Health Science Center.
Availability of data and materials
The dataset used and/or analyzed during the current study are available
from the corresponding author on reasonable request.
Rahman et al. BMC Pediatrics (2018) 18:311
Authors’ contributions
All authors give consent for publication and approved of the final manuscript. AR
conducted the data analysis, drafted the initial manuscript, and approved the final
manuscript. KF was PI on one study and co-I on the other study from which data
were analyzed, oversaw the data analysis, drafted the initial manuscript, and
approved the final manuscript. SFF provided input for the design and analysis of
the study, edited the initial manuscript, and approved the final manuscript. SIF
provided input for the design and analysis of the study, edited the initial
manuscript, and approved the final manuscript. NH was PI on one study and co-I
on the other study from which data were analyzed, edited the initial manuscript,
and approved the final manuscript. OM edited the initial manuscript and
approved the final manuscript.
Ethics approval and consent to participate
Approval was obtained from the UNT Health Science Center Institutional
Review Board. Written informed consent was obtained from all parent
participants, and written assent was obtained from all child participants.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Division of Epidemiology and Community Health, School of Public Health,
University of Minnesota, 1300 S 2nd Street, Suite 300, Minneapolis, MN
55454, USA. 2North Texas Primary Care Practice-Based Research Network
(NorTex), University of North Texas Health Science Center at Fort Worth, 3500
Camp Bowie Blvd, Fort Worth, TX 76107, USA. 3Department of Family
Medicine, Texas College of Osteopathic Medicine, University of North Texas
Health Science Center at Fort Worth, 3500 Camp Bowie Blvd, Fort Worth, TX
76107, USA. 4Department of Pediatrics, Texas College of Osteopathic
Medicine, University of North Texas Health Science Center at Fort Worth,
3500 Camp Bowie Blvd, Fort Worth, TX 76107, USA.
Received: 25 April 2017 Accepted: 16 September 2018
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53. Wang Z, Patterson CM, Hills AP. Association between overweight or obesity
and household income and parental body mass index in Australian youth:
analysis of the Australian National Nutrition Survey, 1995. Asia Pac J Clin
Nutr. 2002;11(3):200–5.
 International Journal of Obesity (2014) 38, 906–911
© 2014 Macmillan Publishers Limited All rights reserved 0307-0565/14
www.nature.com/ijo

PEDIATRIC ORIGINAL ARTICLE

Obesity and depression in adolescence and beyond:
reciprocal risks
NR Marmorstein1, WG Iacono2 and L Legrand2

OBJECTIVE: Obesity and major depressive disorder (MDD) are associated, but evidence about how they relate over time is
conflicting. The goal of this study was to examine prospective associations between depression and obesity from early adolescence
through early adulthood.
METHODS: Participants were drawn from a statewide, community-based, Minnesota sample. MDD and obesity with onsets by early
adolescence (by age 14), late adolescence (between 14 and 20) and early adulthood (ages 20–24) were assessed via structured
interview (depression) and study-measured height and weight.
RESULTS: Cross-sectional results indicated that depression and obesity with onsets by early adolescence were concurrently
associated, but the same was not true later in development. Prospective results indicated that depression by early adolescence
predicted the onset of obesity (odds ratio (OR) = 3.76, confidence interval = 1.33–10.59) during late adolescence among females.
Obesity that developed during late adolescence predicted the onset of depression (OR = 5.89, confidence interval = 2.31–15.01)
during early adulthood among females.
CONCLUSIONS: For girls, adolescence is a high-risk period for the development of this comorbidity, with the nature of the risk
varying over the course of adolescence. Early adolescent-onset depression is associated with elevated risk of later onset obesity,
and obesity, particularly in late adolescence, is associated with increased odds of later depression. Further investigation into the
mechanisms of these effects and the reasons for the observed gender and developmental differences is needed. Prevention
programs focused on early-onset cases of depression and adolescent-onset cases of obesity, particularly among females, may help
in reducing risk for this form of comorbidity.
International Journal of Obesity (2014) 38, 906–911; doi:10.1038/ijo.2014.19
Keywords: depression; comorbidity; prospective; adolescence

INTRODUCTION physiological factors involved in regulating mood and weight

Major depressive disorder (MDD) and obesity are associated;1,2
however, the nature and directionality of this association remains
unclear. Estimates of risk indicate that people with one of these
disorders at some point during their lifetimes are at ~ 1.5–2 times
increased risk of having the other disorder, with some subgroups
(for example, women) with one of these disorders experiencing
more than double the risk for the other disorder compared with
non-affected people.3–6 Owing to possible developmental differ-
ences in these associations and limitations of the present
literature, the goal of this study was to describe the cross-
sectional and prospective, across-time associations between these
disorders from early adolescence through early adulthood.
There are three possible pathways that could account for the
comorbidity of these disorders: obesity may predispose people to
depression, depression may predispose people to obesity or a
third factor may predispose people to both. Obesity could lead to
depression through weight stigma,7 poor self-esteem8 and/or
functional impairment (reduced mobility and ability to engage in
activities9). Depression could lead to obesity directly through the
occurrence of depressive symptoms (for example, increased
appetite, poor sleep,10 lethargy resulting in decreased calorie
expenditure and/or reduced energy to obtain and cook healthy
foods), antidepressant medication side effects11 or attempts to
self-medicate depressive feelings with unhealthy foods. Common
could result in this pattern of co-occurrence as well,12 as could
environmental common factors (for example, poverty, leading to
hopelessness and reduced access to healthy food and safe
recreational activities).
Age may moderate this association, such that childhood and
adolescence may be a particularly vulnerable period for the
development of this form of comorbidity. There are three broad
reasons for this. First, early-onset cases are likely to be reflective of
more severe liabilities to these disorders, which may be shared
biologically12 or environmentally. Second, either disorder occurring
early in development may be more likely to affect long-term
psychological and behavioral characteristics than would disorders
that have onsets later in development. Considering obesity-
to-depression pathways, a child who is obese may be particularly
susceptible to negative societal messages about obesity, teasing or
bad feelings stemming from poor performance in sports; these
could increase risk for MDD. In contrast, an adult woman who
developed obesity after menopause may be less susceptible to
MDD because she already would have a sense of herself as a
worthwhile person, her peers would be less likely to tease her and
she would not experience mandatory engagement in activities like
gym class. Considering MDD-to-obesity pathways, eating and
activity habits are still being formed in childhood and adolescence.
Therefore, an MDD episode during this period, which could result in

1
Department of Psychology, Rutgers University, Camden, NJ, USA and 2Department of Psychology, University of Minnesota, Minneapolis, MN, USA. Correspondence: Professor
NR Marmorstein, Department of Psychology, Rutgers University, Camden, 311 North 5th Street, Camden, NJ 08102, USA.
E-mail: marmorst@camden.rutgers.edu
Received 13 June 2013; revised 14 January 2014; accepted 24 January 2014; accepted article preview online 31 January 2014; advance online publication, 4 March 2014

reduced activity (owing to anhedonia, low energy and so on) and/or
unhealthy eating (to cope with negative affect or owing to low
self-esteem and not caring for oneself), could predispose the
person to long-term unhealthy habits. In contrast, the onset of
MDD in middle adulthood may result in temporary changes but
would be less likely to result in the long-term changes that would
be necessary to make that person transition from a healthy weight
to an obese weight. Third, there are particular reasons that early-
onset MDD may directly relate to the development of obesity: for
example, sleep disturbance is found in nearly three-quarters of
depressed children,13 and inadequate sleep is a risk factor for
obesity.10 In addition, children and adolescents with MDD differ
from adults with MDD on biological measures that may be
relevant to the co-occurrence of obesity and MDD, such as basal
cortisol secretion and immune responses.14
Both obesity-to-depression and depression-to-obesity pathways
have found empirical support; among community-based long-
itudinal studies, a recent review found that 80% of those
examining obesity-to-depression pathways found evidence for
their statistical significance, whereas 53% of those examining
depression-to-obesity pathways found evidence for their statistical
significance.1 Unfortunately, this literature is characterized by
methodological limitations.1 At a basic level, of community-based
longitudinal studies, only one has used study-measured (as
opposed to self-reported) height and weight (and resulting
obesity diagnoses) and clinical interview assessments of MDD
(as opposed to questionnaire measures of depression15). Most
studies do not examine potential developmental change in the
association between obesity and depression, and not all examine
potential differences by sex.1
The goal of this study was to examine cross-sectional and
prospective associations between MDD and obesity in a
community-based sample of youth followed prospectively from
age 11 through age 24. Our focus was on obesity and MDD with
onsets during adolescence, with specific examinations of onsets
during early (by age 14) and late (between ages 14 and 20)
adolescence. We focused specifically on disorder onsets—not
recurrence or persistence—because the earlier occurrence of each
disorder strongly predicts its later occurrence. Therefore, we
believed that understanding factors related specifically to the
initial development of each disorder was crucial. We expected that
disorders with onsets during the adolescent period would be
particularly problematic for the reasons outlined above. Strengths
of this study included the following: (1) the use of study-assessed
height and weight measurements and resulting obesity diagnoses,
(2) the use of clinical interview-based diagnoses of MDD; (3)
participant assessments at five uniform ages (11, 14, 17, 20 and
24), thereby allowing for the consideration of potential develop-
mental differences; and (4) the examination of potential gender
differences in these associations.
On the basis of previous research on MDD-obesity comorbidity
and theory regarding the effects of development, we expected
cross-sectional associations between these disorders to be
significant, particularly earlier in development. Earlier MDD was
expected to predict the later onset of obesity and earlier obesity
was expected to predict the later onset of MDD. Although we
expected that disorders developing during adolescence would be
particularly predictive of the later development of the other
disorder, based on a lack of previous literature, we did not make
specific predictions regarding whether early or late adolescence
would be more influential.
MATERIALS AND METHODS
Participants
Participants were drawn from the Minnesota Twin Family Study, a
community-based sample of adolescents and their families. This sample
was utilized because the participants were representative of Minnesota
© 2014 Macmillan Publishers Limited
Obesity and depression in adolescence and beyond
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907
families with children living at home (based on the 2000 US Census)16 and
because it included rigorous, developmentally timed assessments of key
study variables (see above). Of eligible families, 83% participated. Youth
were born between 1977 and 1982 (men) or 1981 and 1985 (women).
Participants (752 men, 760 women) were first recruited and assessed when
the youth were 11 (mean = 11.7, s.d. = 0.4) and were invited back to return
to the study at ages 14 (mean = 14.8, s.d. = 0.5), 17 (mean = 18.2, s.d. = 0.7),
20 (mean = 21.5, s.d. = 0.8) and 24 (mean = 25.3, s.d. = 0.7). Retention was
strong (participation rates averaged over 90% at each wave). Although
twin zygosity was not considered in this report, both monozygotic
(N = 487) and dizygotic (N = 269) pairs comprised the sample. This study
was approved by the University of Minnesota institutional review board,
and participants gave informed consent (if 18 or over, or parent on behalf
of a minor child) or assent (for minors).
Consistent with the population of the state of Minnesota at the time these
youth were born, ~ 95% of the sample was White. Additional information
about the study design and participants is provided elsewhere.17
Measures
MDD. MDD was assessed in youth younger than age 17 using the
Diagnostic Interview Schedule for Children and Adolescents18 and in youth
aged 17 and older using the Structured Clinical Interview for DSM-III-R
(Diagnostic and Statistical Manual of Mental Disorders, 3rd edition,
revised).19 Diagnostic interviews were conducted in person by trained
interviewers with bachelor’s or master’s degree in Psychology, reviewed by
teams of advanced clinical psychology doctoral students who achieved
consensus agreement for each assessed symptom of MDD, and diagnosed
using computer algorithms following DSM rules (κ = 0.78 or better). For
youth aged 17 and younger, diagnoses reported by either the mother or
the child were counted as present (the best-estimate method20–22).
Definite and probable (exhibiting all symptoms necessary for the diagnosis
except one23) diagnoses were used. At the initial assessment, lifetime
diagnoses were assessed; after that, MDD was assessed since the last visit
to the study. Diagnoses reported at either age 11 or age 14 were combined
into an assessment of MDD during early adolescence. If MDD was first
reported at 17 or 20, this was considered to represent late adolescent-
onset MDD. If MDD was first reported at 24, this was considered to
represent an onset of MDD during early adulthood.
Obesity. Height and weight were assessed using a Detecto mechanical
physician scale with height rod. Body mass index was calculated using the
standard formula (weight in kilograms divided by height in meters
squared). For youth at age 20 and 24, the standard body mass index cutoff
of 30 was used to define obesity. For youth younger than age 20, growth
curves from the Center for Disease Control24 were used to determine
obesity cutoffs (95th percentile) for each age and sex based on the average
participant ages at each assessment24,25 (age 11: 23.90 for men, 24.89 for
women; age 14: 26.71 for men, 27.99 for women; age 17: 28.90 for men, 30
for women). Analogous to MDD, obesity first occurring at age 11 or age 14
was combined into an assessment of obesity during early adolescence.
If obesity was first present at 17 or 20, this was considered to represent late
adolescent-onset obesity. If obesity was first present at 24, this was
considered to represent an onset of obesity during early adulthood.
Statistical analyses
SAS version 9.2 (Cary, NC, USA) was employed to compute generalized
estimating equations (PROC GENMOD) to account for the correlated
observations in this sample (twins nested within families26). This procedure
fits generalized linear models using maximum-likelihood methods.
Specifically, logistic regression models for binomial data were used. The
default correlation structure (independent) was used. There was little
missing data because if a participant missed an early assessment, the
relevant data for the missed assessment were obtained in a subsequent
assessment. In cases where a data point was missing, PROC GENMOD
excludes that individual from that analysis.
First, prevalences of the onset of each disorder during each develop-
mental period, as well as anytime before the final assessment, were
computed and compared across sex using generalized estimating
equations. Next, in order to examine cross-sectional associations between
these disorders, tetrachoric correlations were conducted (reported with
asymptotic standard errors) to describe the associations between MDD
and obesity with onsets occurring within each developmental stage (early
International Journal of Obesity (2014) 906 – 911
 Obesity and depression in adolescence and beyond
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908
adolescence, late adolescence and early adulthood), as well as onsets
anytime before the final assessment.
For the prospective (that is, across time) analyses that were the focus of
our study, because of our interest in disorder onsets (rather than the
recurrence or persistence of disorders), some participants were eliminated
from certain analyses due to their having earlier onset of the disorder. For
example, if a participant experienced MDD before the age of 14, he/she
was not included in analyses predicting obesity onsets in early adulthood
from MDD onsets between 14 and 20 (because the MDD onset had been
experienced before that).
For the prospective analyses, generalized estimating equations were
used. For each analysis described below, two models were examined. The
first examined the overall effect of one disorder on the other, adjusting for
the effect of gender. The second included a disorder-by-gender interaction
term in order to assess the significance of gender differences in the effect
of the independent variable on the dependent variable.
First, we examined whether the occurrence of obesity by age 14
predicted the development of MDD (1) during late adolescence, and (2)
during early adulthood. Second, we examined the association between
obesity first developing during late adolescence and the onset of MDD in
early adulthood. Next, we examined the opposite directions of effect: MDD
by age 14 predicting the development of obesity (1) during late
adolescence and (2) during early adulthood; and MDD first developing
during late adolescence and the onset of obesity in early adulthood.
For inclusion in the analysis, participants were required to have data at
the oldest assessment point within each developmental period (age 14 for
early adolescence, age 20 for late adolescence and age 24 for early
adulthood). Data were occasionally missing at the younger assessment
point (age 11 for early adolescence and age 17 for late adolescence). If a
participant missed one of these assessments, when he or she returned,
MDD was assessed since the previous visit to the study; therefore, these
entire developmental periods were covered. For obesity, the only way a
case would have been missed would be if the participant first became
obese and then became non-obese all within a 6-year period.
RESULTS
Gender differences in the prevalences of MDD, obesity and their
co-occurrence
Prevalences of the onset of each disorder during early adoles-
cence, late adolescence and early adulthood, as well as at any time
before age 24, are presented in Table 1 separately by gender.
Turning to the bottom three rows, by age 24, lifetime rates of
MDD (26.5% men, 36.4% women) and co-occurring MDD and
obesity (7.8% men, 11.9% women), but not obesity considered
alone (25.7% men, 27.5% women), differed by gender, with
women having higher rates than men.
Turning to specific developmental stages, gender differences
were evident for MDD in late adolescence (12.0% men, 18.9%
women) and early adulthood (7.6% men, 12.3% women), with
women showing higher rates than men. As can be seen from
Table 1, the co-occurrence of the onsets of the two disorders at
each developmental stage was uncommon, never attaining a rate
higher than 1.8% for either gender, and thus did not occur with
sufficient frequency to justify computing odds ratios (ORs).
Cross-sectional associations between MDD and obesity
By age 24, the lifetime occurrence of obesity and MDD was
significantly correlated (r = 0.14, s.e. = 0.05, P o0.05). However, of
particular interest was how the correlation between these
conditions varied with development; we expected that there
would be stronger correlations at younger, compared with older,
ages. MDD and obesity were significantly correlated if both
occurred by early adolescence (r = 0.20, s.e. = 0.08, Po 0.05), but
the correlation was not significant when MDD and obesity first
occurred in late adolescence (r = 0.03, s.e. = 0.09) or in early
adulthood (r = 0.09, s.e. = 0.11).
Prospective associations between earlier obesity and later MDD
As can be seen from Table 2, obesity that developed by early
adolescence did not significantly predict the onset of MDD
anytime during the follow-up period (during late adolescence or
early adulthood), although there was a trend for early adolescent
obesity to predict the onset of MDD during the late adolescent
period. Obesity that developed in late adolescence did predict the
onset of MDD in early adulthood among women (a gender-
by-obesity interaction effect; Figure 1).
Prospective associations between earlier MDD and later obesity
As can be seen in Table 2, MDD that developed by early
adolescence predicted the onset of obesity in late adolescence
among women (a gender-by-MDD interaction effect; Figure 2).

Table 1. Gender similarities and differences in the prevalence of obesity, major depressive disorder (MDD) and their co-occurrence during different
developmental stages

Prevalence by gender (%) Gender difference (odds ratio, 95% CI)

Males Females

MDD by early adolescence (14) 7.2 7.0 0.98 (62–1.53)

Obesity by early adolescence (14) 10.7 14.7 1.45* (95–2.20)
Both MDD and obesity by early adolescence (14)a 1.3 1.8
MDD first occurring in late adolescence (14–20) 12.0 18.9 1.72** (1.21–2.43)
Obesity first occurring in late adolescence (14–20) 8.5 6.0 0.68 (40–1.18)
Both MDD and obesity first occurring in late adolescence (14–20)a 1.4 1.0
MDD first occurring in early adulthood (20–24) 7.6 12.3 1.72** (1.12–2.62)
Obesity first occurring in early adulthood (20–24) 7.4 7.7 1.05 (61–1.83)
Both MDD and obesity first occurring in early adulthooda 1.4 0.6 —
MDD with an onset anytime by age 24b 26.5 36.4 1.59*** (1.22–2.07)
Obesity with an onset anytime by age 24b 25.7 27.5 1.09 (79–1.51)
Both MDD and obesity first occurring anytime by age 24c 7.8 11.9 1.68**** (1.05–2.67)
Abbreviations: CI, confidence interval; GEE, generalized estimating equation. *Po0.10; **P o0.01; ***Po0.001; ****Po 0.05. Odds ratios presented in the
rightmost column represent the risk for the indicated disorder associated with being female (compared with being male). Significance levels are derived from
Z-scores computed based on the GEE parameter estimates, with the empirical s.e. estimates used. aOdds ratio not computed owing to small cell size. bTabled
values are not exact sums of the onsets during each developmental period owing to missing data at different assessment points. cTabled values are not sums
of the co-occurrences during each developmental stage owing to many co-occurring cases experiencing onsets during different developmental periods (for
example, MDD during early adolescence and obesity during late adolescence), as well as missing data.

International Journal of Obesity (2014) 906 – 911 © 2014 Macmillan Publishers Limited
 Obesity and depression in adolescence and beyond
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909
Table 2. Prospective associations between obesity and major depressive disorder (MDD)

Risk for new onset of the other disorder in late Risk for new onset of the other disorder in early
adolescence (14–20) adulthood (20–24)

Main effect Interaction effect with Main effect Interaction effect with
gender gender

MDD by early adolescence (14) 1.42 (0.58–3.46) 2.44* (1.14) 1.02 (0.37–2.85) 0.03 (1.05)
N = 932 N = 821
Males: 0.33 (0.05–2.36)
Females: 3.76 (1.33–10.59)

Obesity by early adolescence (14) 1.53** (0.96–2.44) 0.40 (0.51) 0.70 (0.33–1.49) − 0.27 (0.79)
N = 1072 N = 908
MDD first occurring in late adolescence 1.31 (0.61–2.81) −1.13 (0.75)
(14–20) N = 762
Obesity first occurring in late adolescence 2.83*** (1.32–6.09) 2.43* (1.15)
(14–20) N = 731
Males: 0.52 (0.07–4.03)
Females: 5.89 (2.31–15.01)

Abbreviations: CI, confidence interval; GEE, generalized estimating equation. *Po0.05; **Po 0.10; ***P o0.01. Significance levels are derived from Z-scores
computed based on the GEE parameter estimates, with the empirical s.e. estimates used. Predictor variables are in the leftmost column, with outcome
variables in the center and rightmost columns. For example, considering the leftmost column of the top row of results, 1.42 represents the increased odds (OR)
for the onset of obesity by late adolescence among participants with MDD by early adolescence. Figures in the ‘main effect’ columns represent ORs (and 95%
CIs); figures in the ‘interaction effect with gender’ columns represent parameter estimates and associated s.e. and are followed by ORs (and 95% CIs) for each
gender separately. The sample size for each analysis is presented beneath each OR in the ‘main effect’ columns (identical sample sizes apply to the
corresponding interaction effect analyses).

50 20
45 18
% with obesity onset 14-20

40 16
% with MDD onset 20-24

35 14
30 12
25 No obesity onset 14-20 10 No MDD by 14
Obesity onset 14-20 MDD by 14
20 8
15 6
10 4
5 2
0 0
Males Females Males Females
Figure 1. Late adolescent-onset obesity and MDD onset in early Figure 2. Early adolescent-onset MDD and obesity onset in late
adulthood: associations by gender (n = 731). adolescence: associations by gender (n = 932).

MDD that developed in late adolescence did not predict the onset
of obesity in early adulthood.
DISCUSSION
The results of this study indicate that there appears to be
developmental as well as gender differences in the association
between MDD and obesity. MDD occurring by early adolescence
predicted the development of obesity in late adolescence among
women. Conversely, obesity with an onset during late adolescence
predicted the onset of MDD in early adulthood among women.
We did not find evidence for significant prospective associations
between these disorders among men. In addition, MDD and
obesity developing by early adolescence were cross-sectionally
associated with each other; this effect was not present at
later ages.
The results of this study were consistent with our expectations
and highlight the importance of the adolescent period in the
development of comorbidity between these disorders. Regarding
cross-sectional associations, we anticipated that these disorders
would be more strongly related at younger, compared with older,
ages, and MDD and obesity with onsets during childhood and
early adolescence were cross-sectionally related while disorders
with later onsets were not. It is important to note that within this
key developmental period (that is, by age 14), we do not know
which disorder developed first, or whether they developed
simultaneously.
The prospective results were also consistent with expectations,
with each disorder during adolescence predicting the later onset
of the other disorder among women. However, the specific period
of risk differed by disorder. The earliest-onset cases of MDD
appear to be most predictive of later obesity for girls; this could be
for any of the reasons discussed earlier, including the still-
developing eating and activity habits of young people or the

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symptom differences between childhood MDD and MDD in
adults.10,13,14 Interestingly, the earliest-onset cases of obesity were
not the most predictive of later-onset MDD, although they were
concurrently associated with MDD. Although obesity by early
adolescence (age 14) did not significantly predict the later onset
of MDD (although this effect was significant at a trend level, with
obese early adolescents being at 1.5 times the risk of non-obese
adolescents for developing MDD in late adolescence, and no
significant gender difference in this trend), obesity developing
during late adolescence (14–20) was particularly predictive of the
later onset of MDD among women. Perhaps, body-related
insecurities and/or peer pressure relating to body shape and
weight are at a height during this late adolescent period (when
the pressure to conform to peer norms is high and dating
relationships are forming) and therefore young women who
experience the onset of obesity during this time are particularly
vulnerable to the subsequent onset of MDD.
Considering lifetime diagnoses by age 24, both MDD and co-
occurring MDD and obesity were more prevalent among women.
Significant gender interaction effects were found for prospective
associations in both directions, with the increased risk for the
other disorder being found among young women specifically.
These gender differences could be due to any number of factors.
For example, obesity may be a more stigmatized condition among
women27,28 and/or women may be more likely to eat to cope with
negative feelings than men.29 Interestingly, inspection of pre-
valences (Figures 1 and 2) indicates that men with either earlier
disorder were at slightly decreased risk for the development of the
other disorder; this may indicate the presence of significantly
different pathways for the development of these disorders among
men and women.30
The results of this study are broadly consistent with prior
prospective research that used study-assessed MDD and obesity
diagnoses. Specifically, Richardson et al.15 found that MDD
between the ages of 11 and 15 was not associated with obesity
at the age of 26, although later MDD (between ages 18 and 21)
was for women. We also found that effects were strongest on the
adjacent developmental period (early to late adolescence for the
MDD to obesity pathway). However, we did not replicate their
effect of MDD between the ages of 18 and 21 (similar to the latter
half of our late-adolescent period) on later obesity in women; the
reasons for this difference are unclear but may relate to the
examination of the occurrence of MDD and obesity, not
specifically the first onsets of these disorders, performed by
Richardson et al.
The results of this study imply that prevention efforts aimed at
both of these disorders in childhood and adolescence may be
fruitful in decreasing the prevalence of this form of comorbidity. In
particular, preventing MDD by early adolescence has the potential
to decrease the later onset of obesity, and preventing the
development of obesity during later adolescence (and perhaps
early adolescence as well, given the trend-level effect found for
that period) has the potential to decrease the prevalence of early
adult-onset MDD, particularly among women. Future research
examining the mechanisms for these findings would be useful for
prevention efforts. For example, if decreased activity among
depressed youth moderates this association, then encouraging
young girls with depression to exercise and/or participate in
sports as they are being treated for depression may prevent the
later onset of obesity.
Although we found differences in the associations between these
disorders depending on whether we examined the period from
early adolescence to late adolescence or late adolescence to early
adulthood, our methodology did not allow us to directly test for the
presence of developmental differences (for example, by examining
age interaction effects, as we did to test for gender differences).
Therefore, it is possible that the differences in significance that we
found by developmental stage are not indicative of true
International Journal of Obesity (2014) 906 – 911
developmental differences. For instance, although obesity first
occurring in late adolescence was strongly associated with increased
odds of MDD (OR = 2.83), obesity occurring by early adolescence
showed a weak association with MDD (OR = 1.53) that just missed
significance (see Table 2). As we have noted above, from this we
would not conclude that risk is only elevated in late adolescence.
However, a somewhat different picture emerged for MDD as a risk
factor for obesity, especially in girls. The interaction effect for MDD
by early adolescence leading to obesity was significant, indicating
that the risk was especially elevated for girls (OR = 3.76). For MDD
first occurring in late adolescence, the interaction effect was not only
not significant, but in the opposite direction, indicating that for girls,
MDD was associated with nonsignificant but slightly reduced risk of
obesity. Although this pattern of results cannot rule out that MDD
first occurring in late adolescence is associated with elevated risk for
obesity, it nonetheless offers plausible support backing the
hypothesis that the key risk period in the MDD to obesity association
is in early adolescence for girls. In sum, until other research directly
examines interaction effects by age, it is important to consider the
developmental differences we found to be tentative.
This study had limitations. For example, the sample was
overwhelmingly White. It is not clear how these results would
generalize to other samples; however, other research has not
found different associations between these disorders among
African-American and White adolescents31 and our sample was
representative of the state of Minnesota at the time these
participants were born.16
In sum, the results of this study indicate that among women,
MDD occurring by early adolescence predicts the later onset of
obesity. Conversely, adolescent-onset obesity among women
(perhaps particularly obesity with an onset in late adolescence)
predicts the later onset of MDD. In addition, the onsets of these
disorders are cross-sectionally associated in childhood and early
adolescence, but not later. Research investigating possible
mechanisms accounting for these differing associations in
different developmental periods would be useful.32 In addition,
studies examining prevention and treatment efforts focusing on
early-onset cases of MDD and adolescent-onset cases of obesity
are warranted, as these may be most likely to reduce risk for the
later development of the other disorder.
CONFLICT OF INTEREST
The authors declare no conflicts of interest.
ACKNOWLEDGEMENTS
This research was supported by the following grants from the National Institutes
of Health: DA022456, DA05147 and AA09367.
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International Journal of Obesity (2014) 906 – 911
 BMI Development and Early
Adolescent Psychosocial Well-Being:
UK Millennium Cohort Study
Yvonne Kelly, PhD,a Praveetha Patalay, PhD,b Scott Montgomery, PhD,c Amanda Sacker, PhDa

BACKGROUND AND OBJECTIVES: The underlying influences on different patterns of BMI abstract
development are not well understood, and psychosocial outcomes linked to BMI
development have been little investigated. Objectives were to identify BMI developmental
trajectories across the first decade of life, examine early life predictors of trajectory
membership, and investigate whether being on a particular BMI trajectory is associated
with markers of psychosocial well-being.
METHODS: We used latent class analysis to derive BMI trajectories by using data collected
at ages 3, 5, 7, and 11 years on 16 936 participants from the Millennium Cohort Study.
Regression models were used to estimate predictors of BMI trajectory membership and
their psychosocial correlates.
RESULTS: Four trajectories were identified: 83.8% had an average “stable” nonoverweight
BMI, 0.6% were in a “decreasing” group, 13.1% had “moderate increasing” BMIs, and
2.5% had “high increasing” BMIs. Predictors of “moderate” and “high” increasing group
membership were smoking in pregnancy (odds ratios [ORs] = 1.17 and 1.97, respectively),
maternal BMI (ORs = 1.10 and 1.14), skipping breakfast (ORs = 1.66 and 1.76), nonregular
bedtimes (ORs = 1.22 and 1.55). Children in the “moderate” and “high” increasing groups
had worse scores for emotional symptoms, peer problems, happiness, body satisfaction, and
self-esteem, and those in the “high increasing” group were more likely to have tried alcohol
and cigarettes.
CONCLUSIONS: Several potentially modifiable early life factors including smoking in pregnancy,
skipping breakfast, and bedtime routines were important predictors of BMI development
in the overweight and obese range, and high BMI growth was linked to worse psychosocial
well-being.
NIH

aDepartment of Epidemiology and Public Health, University College London, London, United Kingdom; bCentre for
WHAT’S KNOWN ON THIS SUBJECT: Distinct patterns
Longitudinal Studies, University College London Institute of Education, London, United Kingdom; and cSchool of of BMI development exist over the childhood years.
Medical Sciences, Örebro University, Örebro, Sweden
WHAT THIS STUDY ADDS: Several potentially
Prof Kelly conceptualized and designed the study and drafted the initial manuscript; Dr Patalay modifiable early life factors are linked to BMI
carried out the analyses and reviewed and revised the manuscript; Prof Montgomery critically growth patterns in the overweight and obese range
reviewed the manuscript; Prof Sacker assisted in the design of the study, advised on data through childhood. BMI growth trajectories in the
analysis, and critically reviewed the manuscript; and all authors approved the final manuscript as overweight and obese range through childhood are
submitted. associated with worse psychosocial well-being in
DOI: 10.1542/peds.2016-0967 early adolescence.
Accepted for publication Sep 7, 2016
Address correspondence to Yvonne Kelly, PhD, Department of Epidemiology and Public Health,
To cite: Kelly Y, Patalay P, Montgomery S, et al. BMI
University College London, 1-19 Torrington Place, London, WC1E 6BT, UK. E-mail: y.kelly@ucl.ac.uk
Development and Early Adolescent Psychosocial Well-
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Being: UK Millennium Cohort Study. Pediatrics. 2016;138(6):
e20160967

PEDIATRICS Volume 138, number 6, December 2016:e20160967 ARTICLE

Overweight and obesity are linked
to health throughout the life course.
A growing body of research suggests
the existence of distinct BMI
development trajectories through
childhood.1–12 Previous studies
have identified 3 broad types of
trajectories: a majority group with
“healthy” BMI throughout childhood,
groups who develop BMI in the
overweight range at some point
during childhood, and those with
BMI in the overweight or obese range
throughout childhood.1–6 Underlying
influences on different patterns
of BMI development are not well
understood, but factors reported to
predict childhood BMI trajectories
include mother’s BMI,1,3,5,6,8,10,11
smoking during pregnancy,1,5,6 and
sociodemographic background.1–5,12
Previous work suggests that a range
of early life factors including infant
feeding, diet, physical activity, and
family routines are associated with
child overweight and obesity.13
However, comparison of study
findings is often hampered for 2
main reasons. The first is differences
in study design used, such as
representative population1–6 versus
convenience samples.7–9 Second,
studies often consider different
potential influences for BMI growth,
overweight, or obesity.
Apparent links between overweight
and obesity and psychosocial well-
being exist, although the direction of
association is not clear, and may be
bidirectional. Several studies indicate
that early psychosocial stress and
adverse family environments are
associated with an elevated risk of
obesity,14–17 and many others suggest
that being overweight or obese
is linked to elevated risks of poor
psychosocial well-being, including
low self-esteem and depressive
symptoms.16,17 One previous
study examined BMI development
trajectories and adolescent
psychosocial well-being and
showed that the exploration of risky
behaviors such as tobacco smoking
2 KELLY et al
was more common for those who
were obese throughout childhood.18
Given that healthy development early
in life has long-lasting consequences,
improving our understanding
of the factors influencing BMI
development, and of how particular
BMI trajectories relate to markers
of well-being, could have important
implications for health throughout
the life course.
To our knowledge this is the
first article that uses nationally
representative data from the UK
to address the following research
objectives:
• Identify BMI developmental
trajectories across the first decade
of life. We derive trajectories
empirically by using latent
class analysis to group subject
with similar patterns of BMI
development. We hypothesize
there will be distinct BMI growth
trajectories, including BMI growth
patterns in the overweight and
obese range, and a nonoverweight
trajectory.
• Examine early life predictors
of trajectory membership. We
hypothesize that some factors,
including cigarette smoking,
factors linked to family routines
including skipping breakfast and
nonregular bedtimes, delayed
infant motor development, low
levels of physical activity, and
dietary indicators such as low
fruit consumption and intake of
sugary drinks, will increase the
risk of having BMI growth in the
overweight and obese range,
whereas breastfeeding will have a
protective role.
• Investigate whether BMI trajectory
membership is associated with
markers of psychosocial well-
being, including socioemotional
difficulties, self-esteem, happiness,
and risky behaviors in early
adolescence. Here, we hypothesize
that having BMI growth in the
overweight or obese range will
correlate with poorer psychosocial
well-being, an umbrella term that
here encompasses socioemotional
difficulties, low self-esteem,
unhappiness, and risky behaviors
such as cigarette smoking and
alcohol consumption.
METHODS
Participants
Data were from the first 5 sweeps
of the UK Millennium Cohort Study,
a prospective study of children
born into 19 244 families, sampled
from all live births in the United
Kingdom between September 2000
and January 2002.19 The first sweep
of data was collected when cohort
members were ~9 months old, and
the subsequent 4 sweeps of data
were collected at ages 3, 5, 7, and
11 years. We used data from the
latter 4 sweeps (ages 3, 5, 7, and 11
years) to estimate trajectories of BMI
development.
A total of 17 601 families participated
in at least 1 of the 4 sweeps, of which
245 multiple births (234 sets of
twins and 11 sets of triplets) were
excluded from analysis. Another 186
participants had no BMI data at any
sweep and were excluded from our
analyses. After we dealt with outlier
BMI values (described below), there
were 14 205, 14 790, 13 457, and
12 697 participants with BMI data at
sweeps 2 to 5, respectively. A total of
16 936 participants were included in
the trajectory analysis, of whom 9523
(56.2%) had data in all 4 sweeps,
3810 (22.5%) in any 3, 2024 (12.0%)
in any 2, and the remaining 1579
(9.3%) in 1 sweep.
BMI
At ages 3, 5, 7, and 11 years children
were weighed and had their height
measured without shoes or outdoor
clothing. Weights in kilograms
to 1 decimal place and heights
to the nearest millimeter were
recorded.20 These measures were
used to calculate BMI. Values were
considered to be outliers if BMI was
<10 or >50, resulting in 6, 0, 3, and
5 values from each of sweeps 2 to 5
being removed, respectively. Mean
(SD) values at each sweep were 16.5
(2.1), 16.4 (1.9), 16.7 (2.4), and 19.3
(3.7).
Sociodemographic Characteristics
Cohort members were classified into
7 groups based on their ethnicity as
reported by their mothers: white,
Indian, Pakistani, Bangladeshi,
black Caribbean, black African,
and other.21 Household income
was categorized into equivalized
quintiles. Occupational class was
indicated according to the standard
National Statistics Socioeconomic
Classification 3-group categorization
(higher managerial, administrative,
and professional; intermediate;
and routine and manual; with an
additional category, never worked
and long-term unemployed). Highest
maternal education attained at sweep
1 was grouped into 6 categories:
higher education including degree
or professional diploma or higher;
Advanced Levels [A-levels], which
are UK school leaving examinations
taken at age 17 to 18 years; General
Certificate of Secondary Education
[GCSEs], which are UK school
examinations at age 15 to 16 years,
broken down into A–C grades and
D–G grades; other qualifications
including overseas qualifications; and
none).
Pregnancy and Infancy Factors
Health-related behaviors during and
after pregnancy that were included
were whether the mother smoked
during pregnancy, ever breastfed
the child, and introduced solid foods
before 4 months of age. Motor delay
in infancy (9 months) was estimated
based on delay compared with
the rest of the cohort in any key
motor skills (sitting, crawling, and
standing).22
PEDIATRICS Volume 138, number 6, December 2016
Early Childhood Factors
Mother’s BMI at age 3 (sweep 2) was
estimated from self-reported height
and weight. Early childhood factors
included markers of diet, physical
activity, and sleep at age 5 years.
Dietary factors were whether the
child drank mainly sugary drinks
(eg, cola, milkshakes, fruit juice) in
between meals, ate <3 portions of
fruit a day, and regularly skipped
breakfast. Sports participation (less
than once per week) was included
as a marker of physical activity.
Television viewing for >3 hours
a day was included as a marker
of sedentary behavior. Whether
the cohort member had a regular
bedtime and, if so, whether this
bedtime was late (9 PM or later at age
5 years) were included as markers of
sleep.
Psychosocial Well-Being Outcomes
At age 11, markers of psychosocial
well-being included socioemotional
difficulties and skills (as indicated
by the parent-reported Strengths
and Difficulties Questionnaire23),
including emotional symptoms,
conduct problems, hyperactivity,
peer problems, and prosocial
behavior. Higher emotional
symptoms, conduct problems,
hyperactivity, and peer problem
scores indicate more difficulties,
whereas high prosocial scores
indicate better outcomes. Cohort
members themselves reported
on antisocial activity (stealing,
being noisy or rude in public
spaces, damaging public property),
exploratory health behaviors (ever
having smoked cigarettes and ever
having drank alcohol), self-esteem
(as indicated by the Rosenberg self-
esteem scale, with lower scores
indicating worse outcomes),24 and
happiness (as indicated by a 6-item
measure of “happiness” with school
work, appearance, family, friends,
school, and life as a whole, with
responses to each item on a 7-point
scale from completely happy to not
at all happy, α = 0.83).25 Additionally,
the marker of body satisfaction
(happiness with appearance) from
the happiness scale was examined as
a separate item.
Analysis
Trajectories of BMI development
were identified via Latent Class
Growth Analysis in Mplus,26
with full information maximum
likelihood estimation to account
for missing BMI data at any time
point. The selection of the number of
trajectories to explore in additional
analyses was based on a range of
criteria including model comparison
(Lo–Mendell–Rubin likelihood ratio
test, likelihood ratio difference),
improvement in information criteria
(Akaike information criterion,
adjusted Bayesian information
criterion [A-BIC]), neatness of
classification (entropy index),
and theoretical interest.27,28 The
4-trajectory model was chosen
for additional analysis (A-BIC plot
indicated a clear flattening of A-BIC
subsequent to the 4-trajectory
model, entropy of 0.88 suggested
satisfactory neatness of classification,
likelihood ratio difference indicated
highly significant improvement
in model fit [P < .001], and Lo–
Mendell–Rubin likelihood ratio test
indicated that 4- versus 3-class was
an improvement [P < .10], whereas
≥5-class was not [P > .50]).
Once trajectories had been derived,
in the next stage, multiple imputation
was carried out to ensure that no
data were excluded in analysis
because of missingness on the
predictors of interest while also
maintaining the survey structure
in the data. During imputation
the trajectory group of subjects
was also included alongside all
the other covariates to inform the
imputation. Overall, 14.6% of data
points across the entire sample,
including the sociodemographic,
infancy, childhood, and age 11
outcome variables, were missing.
3

FIGURE 1
Average BMI for each of the identified trajectories at ages 3, 5, 7, and 11 years. Overweight and obese
ranges use International Obesity Task Force (IOTF) age specific cut points.
The proportion of data missing
varied by variable; for example,
no cases were missing for gender,
0.1% were missing for income, and
0.6% were missing for ethnicity
(not imputed) on the lower end, and
28.5% were missing for the Strengths
and Difficulties Questionnaire
and 29.6% were missing for self-
esteem at age 11 years on the
higher end. Missingness on markers
of psychosocial well-being was
consistently lowest for subjects in
the “moderate increasing” BMI group
(average missing 18.9%), followed by
the “stable” group (average missing
28.7%), and the “high increasing”
BMI group (average missing 30.2%),
and the highest missingness was
observed in children in the smallest
group, with decreasing BMI over
childhood (average missing 35.8%).
Guided by best practice,29 we carried
out 25 imputations and used them in
subsequent analysis. Supplemental
Table 4 provides information on the
nonimputed and imputed descriptive
statistics for all variables in the study.
Predictors of membership to different
trajectory groups were investigated
via multivariate multinomial
4 KELLY et al
logistic regressions comparing
the decreasing and increasing
trajectories to the reference group
(the largest, “stable” trajectory).
Psychosocial outcomes at age 11
(socioemotional difficulties and skills,
antisocial behaviors, exploratory
risky behaviors, self-esteem,
and happiness) were examined
by trajectory group to ascertain
whether different trajectories were
associated with different outcomes.
Sociodemographic variables were
adjusted for in these analyses, and
we present odds ratios for potential
predictors that are independent of
all factors. In addition, we carried out
sensitivity analysis for participants
with data on markers of puberty, but
this analysis did not alter estimates
and is not reported.
RESULTS
Of the 16 936 participants with BMI
data in any of the sweeps, 48.8%
(n = 8259) were girls. Most of the
sample (83.8%) had an average
nonoverweight BMI (the “stable”
trajectory). The smallest decreasing
trajectory group (0.6%) had BMIs
in the obese range at age 3 but
were similar to the stable group by
age 7. The “moderate increasing”
group (13.1%) had average BMIs
in the nonoverweight range at age
3 and subsequent average BMIs
that increased throughout the rest
of childhood into the overweight
but not obese range. The “high
increasing” trajectory (2.5%) had
average BMIs in the obese range at
age 3, and their BMIs continued to
increase throughout childhood
(Fig 1).
What Factors Predict BMI Trajectory
Membership?
Table 1 shows the distribution of
predictor variables by BMI trajectory
group. Fully adjusted estimates,
simultaneously taking account of
all variables, are shown in Table 2.
Sociodemographic variations in
trajectory membership were seen.
Girls were more likely to be in the
“moderate increasing” group (odds
ratio [OR] = 1.36) and less likely to be
in the “decreasing” trajectory (OR =
0.44). Indian, Pakistani, and black
African children were significantly
more likely to have a “moderate
increasing” trajectory (ORs = 1.66,
1.29, and 2.01, respectively), and
Pakistani, black Caribbean, and black
African children were more likely
to belong to the “high increasing”
group (ORs = 1.83, 3.44, and 3.39,
respectively). Compared with cohort
members in the affluent income
quintile, those in the other 4 income
groups had higher odds of being
in the “moderate increasing” BMI
group. Low maternal educational
attainment compared with degree or
higher levels predicted membership
of increasing trajectories (GCSE
grades A–C and D–G “moderate
increasing” ORs = 1.32 and 1.42,
respectively; GCSE grades A–C and no
qualifications “high increasing” ORs =
1.79 and 1.74, respectively).
Cohort members whose mothers
smoked during pregnancy had higher
odds of being in the “moderate
increasing” and “high increasing”
TABLE 1 Distribution of Predictor and Outcome Variables by Derived BMI Trajectories
Stable Decreasing Moderate Increasing High Increasing Overall
Mean % (95% CI) Mean % (95% CI) Mean % (95% CI) Mean % (95% CI) Mean % (95% CI)
Sociodemographic
characteristics
Gender, % female 47.9 (46.8 to 48.9) 29.2 (18.3 to 40.1) 55.6 (53.3 to 57.9) 51.8 (46.2 to 57.5) 48.8 (47.9 to 49.7)
Ethnicity
White, % 88.1 (86.1 to 90.1) 84.6 (76.0 to 93.1) 83.8 (80.5 to 87.2) 78.5 (72.8 to 84.1) 87.4 (85.2 to 89.5)
Indian, % 2.1 (1.6 to 2.7) 0.0 2.7 (1.8 to 3.6) 1.8 (0.3 to 3.3) 2.2 (1.6 to 2.8)
Pakistani, % 2.9 (1.7 to 4.2) 2.8 (−0.6 to 6.3) 3.8 (2.0 to 5.6) 4.5 (2.0 to 6.9) 3.1 (1.8 to 4.4)
Bangladeshi, % 0.9 (0.5 to 1.4) 0.5 (−0.5 to 1.4) 1.2 (0.5 to 1.9) 1.7 (0.2 to 3.2) 1.0 (0.5 to 1.4)
Black Caribbean, % 2.0 (1.5 to 2.5) 6.2 (−0.4 to 12.9) 2.5 (1.6 to 3.5) 6.7 (3.8 to 9.6) 2.2 (1.6 to 2.7)
Black African, % 1.6 (1.1 to 2.1) 4.2 (−0.3 to 8.8) 3.5 (2.0 to 5.1) 4.7 (2.1 to 7.4) 1.9 (1.3 to 2.6)
Other, % 2.3 (1.8 to 2.8) 1.7 (−0.9 to 4.3) 2.4 (1.6 to 3.3) 2.2 (0.8 to 3.5) 2.3 (1.9 to 2.8)
Family income
Most affluent quintile, 22.7 (20.2 to 25.2) 13.2 (4.4 to 21.9) 14.1 (11.7 to 16.4) 13.0 (8.7 to 17.2) 21.4 (19.0 to 23.7)
%
4th quintile, % 20.8 (19.7 to 22.0) 15.6 (6.1 to 25.1) 20.7 (18.4 to 23.0) 16.8 (12.5 to 21.2) 20.7 (19.6 to 21.8)
3rd quintile, % 19.7 (18.6 to 20.9) 21.6 (10.7 to 32.4) 21.3 (19.1 to 23.6) 17.7 (13.6 to 21.8) 19.9 (18.8 to 21.0)
2nd quintile, % 18.8 (17.7 to 20.0) 21.6 (12.3 to 30.9) 21.9 (19.8 to 24.0) 24.2 (19.4 to 29.0) 19.3 (18.2 to 20.5)
Least affluent quintile, 17.9 (16.0 to 19.2) 28.1 (16.5 to 39.6) 22.0 (19.5 to 24.5) 28.3 (23.5 to 33.1) 18.7 (17.4 to 20.0)
%
Occupational class
Higher managerial, 32.3 (30.2 to 34.4) 27.5 (15.5 to 39.6) 27.2 (24.3 to 30.0) 22.6 (17.9 to 27.4) 31.4 (29.4 to 33.4)
administrative, and
professional, %
Intermediate, % 22.8 (21.7 to 23.9) 22.6 (12.2 to 33.0) 20.3 (18.2 to 22.4) 17.5 (12.8 to 22.1) 22.4 (21.3 to 23.4)
Routine and manual, % 38.3 (36.3 to 40.2) 40.2 (27.2 to 53.3) 44.2 (41.2 to 47.2) 50.5 (44.6 to 56.5) 39.3 (37.4 to 41.2)
Never worked or 6.7 (5.7 to 7.7) 9.6 (2.9 to 16.4) 8.3 (6.6 to 10.1) 9.4 (6.0 to 12.7) 6.9 (5.9 to 8.0)
unemployed, %
Maternal education level
Degree or higher, % 30.0 (27.6 to 32.3) 26.6 (14.3 to 38.8) 21.7 (19.2 to 24.2) 14.9 (10.5 to 19.3) 28.6 (26.4 to 30.8)
A-levels, % 10.2 (9.5 to 10.8) 8.9 (3.1 to 14.8) 8.7 (7.3 to 10.1) 7.4 (4.5 to 10.3) 9.9 (9.3 to 10.5)
GCSE (A–C), % 33.9 (32.2 to 35.7) 37.2 (24.5 to 50.0) 37.5 (34.8 to 40.2) 39.2 (33.4 to 45.0) 34.5 (32.8 to 36.2)
GCSE (D–G), % 10.0 (9.2 to 10.8) 10.2 (2.5 to 17.8) 13.0 (11.2 to 14.8) 13.1 (8.8 to 17.4) 10.4 (9.6 to 11.3)
Overseas qualification, 2.2 (1.8 to 2.6) 1.0 (−0.2 to 2.1) 2.9 (2.0 to 3.7) 2.4 (0.9 to 3.9) 2.3 (1.9 to 2.7)
%
None, % 13.8 (12.7 to 14.9) 16.2 (7.2 to 25.2) 16.2 (14.2 to 18.3) 23.0 (18.4 to 27.6) 14.3 (13.2 to 15.4)
Pregnancy and infancy
factors
Smoked during 22.4 (21.2 to 23.6) 27.6 (15.6 to 39.6) 25.9 (23.6 to 28.2) 38.4 (32.6 to 44.2) 23.2 (22.0 to 24.4)
pregnancy, % yes
Breastfed child, % no 27.1 (25.4 to 28.8) 30.0 (18.9 to 41.0) 30.9 (28.1 to 33.7) 36.6 (30.4 to 42.8) 27.8 (26.1 to 29.5)
Solids before 4 mo, % yes 17.3 (16.2 to 18.4) 12.0 (4.0 to 20.0) 20.6 (18.5 to 22.6) 24.1 (19.0 to 29.2) 17.8 (16.9 to 18.8)
Motor delay, % yes 10.4 (9.7 to 11.1) 11.4 (2.6 to 20.1) 9.7 (8.2 to 11.3) 15.1 (10.9 to 19.2) 10.4 (9.8 to 11.1)
Early childhood factors
Maternal BMI, mean 24.6 (24.5 to 24.7) 25.4 (24.0 to 26.8) 27.3 (27.0 to 27.6) 28.8 (28.1 to 29.4) 25.0 (24.9 to 25.1)
Sugary drinks, % yes 40.8 (39.2 to 42.3) 33.0 (20.3 to 45.6) 41.9 (39.0 to 44.8) 41.2 (35.3 to 47.0) 40.9 (39.4 to 42.4)
Fruit <3 per d, % yes 45.9 (44.4 to 47.3) 43.6 (28.8 to 58.5) 51.1 (48.3 to 53.9) 55.9 (49.9 to 61.8) 46.7 (45.3 to 48.1)
Skip breakfast,% yes 6.5 (6.0 to 7.0) 13.6 (4.3 to 22.9) 12.0 (10.6 to 14.4) 15.8 (11.5 to 20.1) 7.5 (7.0 to 8.0)
Sport <1 per wk % no 44.5 (42.7 to 46.3) 55.9 (40.9 to 70.8) 47.7 (44.6 to 50.7) 55.9 (49.8 to 61.9) 45.2 (43.5 to 46.9)
Television >3 h/d, % yes 13.7 (12.6 to 14.9) 25.0 (13.6 to 36.4) 17.4 (15.4 to 20.0) 19.7 (15.2 to 24.2) 14.4 (13.3 to 15.5)
Nonregular bedtime, 8.9 (8.2 to 9.5) 12.2 (2.7 to 21.7) 12.6 (10.8 to 14.5) 18.0 (13.0 to 23.1) 9.6 (8.9 to 10.2)
% yes
Late bedtime, % yes 4.7 (4.1 to 5.3) 8.4 (2.7 to 14.1) 6.7 (5.4 to 8.1) 8.2 (5.2 to 11.2) 5.0 (4.4 to 5.7)
Psychosocial and
behavioral outcomes
Emotional symptoms, 1.81 (1.76 to 1.86) 2.25 (1.47 to 3.03) 2.05 (1.92 to 2.18) 2.45 (2.18 to 2.73) 1.85 (1.81 to 1.90)
mean
Conduct problems, mean 1.35 (1.31 to 1.39) 1.79 (1.29 to 2.30) 1.42 (1.34 to 1.51) 1.88 (1.67 to 2.10) 1.37 (1.33 to 1.41)
Hyperactivity, mean 3.10 (3.03 to 3.17) 3.19 (2.49 to 3.90) 3.11 (2.97 to 3.25) 3.57 (3.22 to 3.91) 3.11 (3.05 to 3.18)
Peer problems, mean 1.28 (1.24 to 1.33) 1.83 (1.35 to 2.31) 1.60 (1.50 to 1.71) 2.25 (1.99 to 2.52) 1.34 (1.30 to 1.39)
Prosocial behavior, mean 8.75 (8.72 to 8.79) 8.53 (8.08 to 8.99) 8.92 (8.83 to 9.01) 8.87 (8.67 to 9.06) 8.77 (8.74 to 8.81)

PEDIATRICS Volume 138, number 6, December 2016 5

TABLE 1 Continued
Antisocial activities,
mean
Smoked cigarettes, % yes
Drank alcohol, % yes
Low self-esteem, mean
Unhappiness, mean
Body dissatisfaction,
mean
CI, confidence interval.
TABLE 2 Predictors of BMI Trajectory Membership, Compared With the “Stable” Group
Sociodemographic characteristics
Gender, female
Ethnicitya
Indian
Pakistani
Bangladeshi
Black Caribbean
Black African
Other
Family incomeb
4th quintile
3rd quintile
2nd quintile
Least affluent quintile
Occupational classc
Intermediate
Routine and manual
Never worked or unemployed
Maternal education leveld
A-levels
GCSE (A–C)
GCSE (D–G)
Overseas qualification
None
Pregnancy and infancy factors
Smoked in pregnancy, yes
Breastfed child, no
Solids before 4 mo, yes
Gross motor delay, yes
Early childhood factors
Maternal BMI
Sugary drinks, yes
Fruit <3 per d, yes
Skip breakfast, yes
Sport <1 per wk, no
Television >3 h/d, yes
Nonregular bedtime, yes
Late bedtime, yes
CI, confidence interval.
a Reference group: white.
b Reference group: richest income quintile.
c Reference group: higher managerial, administrative, and professional.
d Reference group: degree or higher.
* P < .05.
** P < .01.
*** P < .001.
6 KELLY et al
Stable Decreasing
Mean % (95% CI) Mean % (95% CI)
0.27 (0.26 to 0.29) 0.35 (0.16 to 0.55)
2.8 (2.4 to 3.2) 0 2.1 (1.3 to 2.8)
12.5 (11.7 to 13.3) 9.8 (0.85 to 18.7)
8.04 (7.99 to 8.10) 7.73 (7.13 to 8.34)
12.39 (12.24 to 12.54) 12.02 (10.19 to 13.84)
2.44 (2.40 to 2.48) 2.45 (1.94 to 2.96)
Decreasing
OR (95% CI)
0.44 (0.27 to 0.71)***
0.00 (0.00 to 0.00)***
0.68 (0.23 to 2.04)
0.34 (0.04 to 2.86)
2.74 (0.82 to 9.11)
2.17 (0.60 to 7.89)
0.64 (0.13 to 3.13)
1.29 (0.54 to 3.11)
1.98 (0.83 to 4.72)
2.14 (0.84 to 5.48)
2.79 (1.08 to 7.18)*
1.01 (0.52 to 1.97)
0.82 (0.36 to 1.87)
1.14 (0.32 to 4.10)
0.85 (0.36 to 1.99)
0.88 (0.40 to 1.91)
0.72 (0.27 to 1.90)
0.30 (0.07 to 1.19)
0.65 (0.26 to 1.65)
1.08 (0.57 to 2.07)
1.05 (0.59 to 1.85)
0.52 (0.25 to 1.10)
1.04 (0.45 to 2.37)
1.03 (0.97 to 1.09)
0.65 (0.37 to 1.14)
0.72 (0.40 to 1.29)
2.01 (1.03 to 3.92)*
1.27 (0.66 to 2.44)
1.86 (0.97 to 3.57)
1.12 (0.49 to 2.59)
1.79 (0.83 to 3.88)
Moderate Increasing High Increasing Overall
Mean % (95% CI) Mean % (95% CI) Mean % (95% CI)
0.28 (0.24 to 0.31) 0.34 (0.25 to 0.43) 0.28 (0.26 to 0.29)
5.1 (2.2 to 8.0) 2.7 (2.4 to 3.1)
14.2 (12.1 to 16.3) 20.9 (14.7 to 27.2) 12.9 (12.1 to 13.7)
8.35 (8.23 to 8.46) 8.88 (8.56 to 9.21) 8.10 (8.05 to 8.15)
13.08 (12.70 to 13.46) 14.54 (13.60 to 15.47) 12.52 (12.38 to 12.67)
2.93 (2.84 to 3.03) 3.42 (3.20 to 3.63) 2.52 (2.49 to 2.56)
Moderate Increasing High Increasing
OR (95% CI) OR (95% CI)
1.36 (1.22 to 1.51)*** 1.20 (0.94 to 1.53)
1.66 (1.24 to 2.23)** 1.63 (0.70 to 3.80)
1.29 (1.02 to 1.65)* 1.83 (1.07 to 3.12)*
1.34 (0.91 to 1.96) 0.46 (0.96 to 6.32)
1.21 (0.90 to 1.61) 3.44 (2.11 to 5.62)***
2.01 (1.42 to 2.86)*** 3.39 (1.94 to 5.94)***
1.21 (0.89 to 1.65) 1.37 (0.71 to 2.63)
1.43 (1.15 to 1.79)** 1.11 (0.70 to 1.77)
1.37 (1.12 to 1.68)** 0.89 (0.53 to 1.50)
1.30 (1.03 to 1.65)* 0.94 (0.56 to 1.57)
1.38 (1.10 to 1.73)** 1.01 (0.57 to 1.81)
0.84 (0.71 to 1.01) 0.81 (0.54 to 1.22)
0.92 (0.77 to 1.10) 0.96 (0.63 to 1.45)
0.92 (0.71 to 1.19) 0.79 (0.44 to 1.43)
1.12 (0.89 to 1.40) 1.39 (0.83 to 2.32)
1.32 (1.11 to 1.57)** 1.79 (1.14 to 2.79)*
1.42 (1.13 to 1.78)** 1.68 (0.95 to 2.96)
1.30 (0.88 to 1.93) 1.32 (0.67 to 2.62)
1.18 (0.95 to 1.48) 1.74 (1.01 to 2.98)*
1.17 (1.03 to 1.33)* 1.97 (1.51 to 2.58)***
1.03 (0.90 to 1.19) 1.18 (0.88 to 1.59)
1.15 (0.98 to 1.34) 1.26 (0.95 to 1.67)
0.92 (0.76 to 1.13) 1.47 (1.05 to 2.04)*
1.10 (1.09 to 1.11)*** 1.14 (1.12 to 1.16)***
1.05 (0.93 to 1.18) 0.99 (0.77 to 1.27)
1.06 (0.94 to 1.19) 1.08 (0.83 to 1.42)
1.66 (1.37 to 2.02)*** 1.76 (1.21 to 2.56)**
0.85 (0.74 to 0.98)* 0.90 (0.69 to 1.19)
1.15 (0.99 to 1.33) 1.17 (0.87 to 1.58)
1.22 (1.01 to 1.46)* 1.55 (1.08 to 2.22)*
1.26 (1.00 to 1.57)* 1.50 (0.93 to 2.41)
TABLE 3 Psychosocial Well-Being at Age 11 y by BMI Trajectory Compared With the “Stable” Group
Stable
Emotional symptoms
Conduct problems
Hyperactivity
Peer problems
Prosocial behavior
Antisocial activities
Smoked cigarettes
Drank alcohol
Low self-esteem
Unhappiness
Body dissatisfaction
Regression analysis included all sociodemographic factors as control variables. All outcomes are linear regressions except smoked cigarettes and drank alcohol which are logistic
regressions. —, no available cases.
* P < .05.
** P < .01.
*** P < .001.
trajectories (ORs = 1.17 and 1.97,
respectively). Breastfeeding and
the early introduction of solid food
were not independently associated
with trajectory membership. Having
motor (sitting, standing, crawling)
delays in infancy were associated
with higher odds of being in the
“high increasing” group (OR = 1.47).
A unit increase in maternal BMI was
associated with a 10% increase in
the odds of being in the “moderate
increasing” and “high increasing”
trajectories. Skipping breakfast and
having nonregular bedtimes in early
childhood were associated with
higher odds of increasing trajectory
membership (for “moderate
increasing,” skipping breakfast
OR = 1.66, nonregular bedtimes OR =
1.22; for “high increasing,” ORs = 1.76
and 1.55, respectively). Sugary drink
consumption, fruit intake, television
viewing, and sports participation
appeared not to predict trajectory
membership.
Are BMI Trajectories Linked to
Psychosocial Well-Being at the Start
of Adolescence?
Compared with the “stable” group,
cohort members in the “moderate
increasing” group had worse
scores for emotional symptoms,
peer problems, happiness, body
satisfaction, and self-esteem but
had better prosocial behavior
scores. Cohort members in the “high
PEDIATRICS Volume 138, number 6, December 2016
Decreasing
0 0.39 (−0.33 to 1.11)
0 0.29 (−0.16 to 0.74)
0 −0.23 (−0.87 to 0.40)
0 0.41 (−0.02 to 0.84)
0 −0.08 (−0.52 to 0.36)
0 0.02 (−0.16 to 0.20)
1 —
1 0.64 (0.24 to 1.72)
0 −0.26 (−0.84 to 0.31)
0 −0.54 (−2.25 to 1.17)
0 0.05 (−0.43 to 0.53)
increasing” group had worse scores
for emotional symptoms, peer and
conduct problems, happiness, body
satisfaction, and self-esteem and
were more likely to have drank
alcohol and smoked cigarettes.
In addition, cohort members in
the “moderate increasing” group
were more likely to have scores
in the clinical range for emotional
and peer problems, and those in
the “high increasing” group were
more likely to have scores in the
clinical range for emotional, peer,
and conduct problems (data not
shown). Belonging to the decreasing
trajectory did not appear to predict
any significantly different outcomes
at age 11 years. The distributions of
psychosocial well-being markers are
shown in Table 1, and fully adjusted
estimates by BMI trajectory are
shown in Table 3.
DISCUSSION
In this large population-based
sample of children we identified 4
BMI development trajectories. The
majority of children belonged to a
stable, nonoverweight group. About
1 in 7 belonged to a group with
increasing BMIs with average BMIs
just under the overweight range at
age 3 and subsequent average BMIs
increasing throughout the rest of
childhood into the overweight but
not obese range. A smaller group
Moderate Increasing High Increasing
0.18 (0.05 to 0.32)** 0.53 (0.25 to 0.80)***
0.03 (−0.06 to 0.11) 0.38 (0.17 to 0.60)***
−0.04 (−0.19 to 0.11) 0.27 (−0.07 to 0.60)
0.27 (0.16 to 0.38)*** 0.84 (0.58 to 1.11)***
0.16 (0.06 to 0.25)** 0.16 (−0.04 to 0.35)
0.00 (−0.04 to 0.03) 0.03 (−0.06 to 0.11)
2.03 (1.65 to 2.75)** 5.05 (2.56 to 16.11)**
1.19 (0.98 to 1.43) 1.82 (1.23 to 2.66)*
0.28 (0.15 to 0.41)*** 0.84 (0.51 to 1.16)***
0.66 (0.27 to 1.06)** 2.07 (1.15 to 2.99)***
0.47 (0.37 to 0.57)*** 0.98 (0.76 to 1.19)***
(2.5%) had average BMIs in the
obese range at age 3, and their BMIs
continued to increase throughout
childhood. A small group (<1%) of
children had BMIs in the obese range
at age 3, but by age 7 their BMIs were
in the nonoverweight range. Factors
that predicted membership in the 2
increasing BMI trajectories included
socioeconomic disadvantage,
being from certain ethnic minority
backgrounds, maternal smoking
during pregnancy, maternal BMI,
and family routines, such as skipping
breakfast and not having regular
bedtimes. We found that, in general,
having BMIs in the overweight and
obese range throughout childhood
was associated with worse
psychosocial well-being at 11 years
of age.
Similar to other reports, a large
proportion of our study sample had
BMIs in the nonoverweight range
throughout childhood,1–5,9,11 and
we identified groups of children
belonging to BMI trajectories in
the overweight or obese range. We
found a small proportion of children
in a decreasing trajectory that has
been seen elsewhere.7 We did not
identify a group of children with
BMIs consistently in the underweight
range. There were differences from
other reports also; for example, some
studies have identified groups of
children who develop overweight
7
or obesity at different points in
childhood, including a late-onset
group.1–4,9,11 Dissimilarities in
observed trajectories might not be
surprising given different study
settings (eg, the United States,2–4,7,8
Canada,5,6,11,12 Australia)1,9,10 and
different empirical approaches used
to identify groups.
Our findings suggest that a range
of early life factors are associated
with children being on particular
BMI trajectories. As found in other
studies, we show sociodemographic
factors including socioeconomic
position1,2,4,12,30 and ethnicity2–4,12
to be linked to membership of
trajectories in the overweight and
obese range. Other work from
the United Kingdom has shown
variations in the risk of overweight
and obesity for children from black
and South Asian groups and for
children living in economically
disadvantaged circumstances.13,31
In keeping with previous reports,
behavioral influences appeared
important, including smoking
in pregnancy,3,5,6,32 maternal
BMI,1–3,5,6,8,10,11,30,32 and markers
of family routines such as skipping
breakfast and sleep schedules.11
Exposure to tobacco products during
fetal life has long been thought to
increase the risk of overweight
in childhood,33 and hypothesized
pathways include altered growth and
weight gain, metabolic processes,
and epigenetic mechanisms.
Previous work suggests links
between fetal tobacco exposure
and infant motor coordination,34
and this link in turn could be on
a developmental pathway to BMI
growth.35 Maternal BMI appears
strongly predictive of children’s
BMI growth, probably reflecting
the wider obesogenic environment
along with genetic predisposition.
Disrupted routines, exemplified
here by nonregular sleep schedules
and skipping breakfast, are
hypothesized to influence weight
gain via increased appetite and
8 KELLY et al
consumption of energy-dense foods.
Interestingly, skipping breakfast
was also associated with being in
the “decreasing” trajectory, but
the potential mechanisms at play
here are not clear. We cannot rule
out, nor were we able to tease out, a
bidirectional relationship between
BMI growth and psychosocial well-
being. As in previous work,14,16,17
our findings suggest that
trajectories in the overweight
and obese range correlate
strongly with worse psychosocial
outcomes, and it may be that the
strength of these associations
increases as adolescence proceeds,
as suggested elsewhere.14,15
Social stigmatization, isolation,
and victimization are factors
hypothesized to form links
between overweight and negative
psychosocial outcomes and
the exploration of risky health
behaviors. Thus, we found that
common psychosocial correlates
of “moderate increasing” and “high
increasing” BMI trajectories were
socioemotional difficulties, low self-
esteem, low overall happiness, and
body dissatisfaction. In addition,
children with BMIs in the obese
range throughout childhood (the
“high increasing” group) were
more likely to report having drunk
alcohol and smoked cigarettes.
This study has distinct strengths,
being the first to examine nationally
representative UK data with
repeated measures allowing for
the empirical derivation of BMI
trajectories across the first decade
of life. We estimated associations
between a wide range of early
life factors, including mother’s
health behaviors (smoking during
pregnancy, infant feeding, and
BMI), infant motor skills, family
routines, diet, and physical activity
in relation to different patterns of
BMI development. Another strength
is that we examined identified BMI
trajectories in conjunction with a
range of markers of psychosocial
well-being, such as socioemotional
difficulties, self-esteem, happiness,
and risky behaviors. This study
has important potential limitations
too. For example, even though we
included in our analyses a wide
range of potential risk factors, we
were not able to fully characterize
influences (including gestational
diabetes and growth in infancy)
that might play a role. Imperfect
measurement was also a feature
for some of our early life predictor
variables, such as sugary drinks,
fruit consumption, and markers
of physical activity including
sports participation and television
viewing, all of which had no
apparent link with BMI trajectories;
however, these markers are
crude, and conclusions based on
null findings should be avoided.
Furthermore, these data on early
life predictors were mother
reported. However, data were
collected contemporaneously,
thus minimizing problems of recall
bias.
CONCLUSIONS
Most children in this contemporary
UK study belonged to BMI
trajectories in the nonoverweight
range. Several potentially
modifiable early life factors,
including smoking in pregnancy
and family routines (skipping
breakfast and not having a regular
bedtime), appeared important in
predicting BMIs in the overweight
and obese ranges. These findings
support the need for intervention
strategies aimed at multiple
spheres of influence on BMI growth.
In general, having BMI growth in
the overweight and obese range
was linked to poorer psychosocial
well-being, supporting the need
for health care providers to
monitor these occurrences in
children with high BMI growth.
Given continuities in overweight
or obesity and mental health
from childhood into adolescence
and adulthood, intervening early
could alter trajectories and have
important implications for physical
health, psychosocial well-being,
and health behaviors across the life
course.
Copyright © 2016 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: The alcohol use and attitudes variables in MCSS were co funded by grant AA019606 from the U.S. National Institute on Alcohol Abuse and Alcoholism. All
phases of this study were supported by a grant from the Economic and Social Research Council RES-596-28-0001. The funders had no role in the interpretation of
these data or in the writing of this article. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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KELLY et al
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OPEN Important gender

differences in psychosomatic
and school‑related complaints
in relation to adolescent weight
status
Samantha J. Brooks1,2,3, Inna Feldman4,5, Helgi B. Schiöth1,6 & Olga E. Titova1,7*

Underweight or overweight in adolescence is linked to several adverse health outcomes. Less evidence
exists about the association between weight status and school-related psychosocial characteristics
in high income countries. We sought to investigate the relationship between weight status and
psychosomatic and school-related complaints with a focus on gender differences. The study is a cohort
of 18,462 adolescents (12–19 years; 51% girls) conducted in Sweden. The associations between weight
status and psychosomatic and school-related complaints were estimated by binary logistic regression
adjusted for several potential confounders. After correction for multiple testing, being underweight
or overweight/obese was adversely associated with several psychosomatic and school-related
complaints with significant differences between boys and girls. Specifically, underweight boys had
higher odds to have psychosomatic complaints than normal-weight boys, while no such associations
were observed among underweight girls. Overweight/obese (vs. normal-weight) boys had higher odds
to complain about headache, pain in the back/hips, and feeling low. Overweight/obese (vs. normal-
weight) girls were more likely to complain about feeling low, anxious/worried and having difficulty
in falling asleep (P ≤ 0.01). In relation to school-related complaints (e.g., being bullied at school and
academic failure), greater associations were observed for overweight/obese girls and boys than for
underweight adolescents compared with normal-weight peers.

Overweight and obesity among children and adolescents has received attention in recent decades as a major
global public health problem, associated with adverse physical and mental health o ­ utcomes1–3. Concomitantly,
modern fashion standards and the ‘thin ideal’ may lead to body dissatisfaction among young p ­ eople4, associ-
ated with weight loss and mental disorders including anxiety, depression and eating disorders such as anorexia
­nervosa5. Research in adolescents indicates that being underweight, overweight/obese or having body image
distortion is associated with increased prevalence of depression, anxiety and suicidal b­ ehavior6–10. This associa-
tion seems to differ across genders. For instance, in a cross-sectional study of 17-year-old adolescents a U-shaped
association between body mass index (BMI) and depression scores was demonstrated in boys, with higher levels
of depression among both underweight and overweight boys. However, a more complex association has been
observed in girls; in support of the “fat and jolly hypothesis”, obese girls were less depressed than overweight,
whereas underweight girls were more depressed than those of normal-weight8. Moreover, a prospective study
of over two thousand U.S. adolescent boys revealed that average weight boys that perceived themselves as being
either very underweight or overweight had higher prevalence of mental disorders such as depression, anxiety
and suicidal behavior, compared to boys who viewed their weight as a­ verage7. Another study of middle school

1
Department of Neuroscience, Uppsala University, Uppsala, Sweden. 2Faculty of Health, School of Psychology,
Liverpool John Moores University, Liverpool  SE3 3AF, UK. 3Neuroscience Research Laboratory (NeuRL),
Department of Psychology, School of Human and Community Development, University of the Witwatersrand,
Johannesburg, South Africa. 4Uppsala County Council, Uppsala, Sweden. 5Department of Public Health and
Caring Sciences, Uppsala University, Uppsala, Sweden. 6Institute for Translational Medicine and Biotechnology,
Sechenov First Moscow State Medical University, Moscow, Russia. 7Unit of Medical Epidemiology, Department of
Surgical Sciences, Uppsala University, Epihubben, Dag Hammarskjölds väg 14 B, 75185 Uppsala, Sweden. *email:
olga.titova@surgsci.uu.se

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students demonstrated that females who perceived themselves as overweight were more likely to report suicidal
thoughts and actions compared to normal-weight adolescents. Importantly, among male students in this study,
perceptions of both being overweight and underweight were related to suicidal thoughts and ­actions9.
The relationship between being underweight or overweight and psychosomatic complaints (PSC) in ado-
lescents is less studied. PSC refer to psychological and physical symptoms experienced by an individual with or
without a defined diagnosis, such as anxiety, depression, headache and stomach ache. PSC have been considered
as possible indicators of poor health among children and a­ dolescents11. For instance, PSC have been previously
associated with stress, poorer well-being and mental ill-health ­symptoms12–14. A Swedish study based on the
Health Behaviour in School-aged Children survey (HBSC) showed increasing rates of mental health complaints
among older adolescents, especially in ­girls15. It has been demonstrated that overweight and obese children and
adolescents as well as those who perceive themselves as overweight are more likely to have health complaints
compared to normal-weight ­peers16,17. However, little is known about health status and health complaints of
underweight adolescents in high-income countries.
Children spend a considerable amount of time at school. Besides the main role of school in the academic
development of children, it plays an important role in social development, physical and mental health. Under-
standing the factors associated with poor perception of school, absenteeism or low academic achievements is of
great importance. For instance, it has been previously suggested that excessive weight may affect school attend-
ance due to its negative effect on physical and mental h ­ ealth18. Thus, a recent meta-analysis has demonstrated
that the odds of being absent from school was 27% and 54% higher among children with overweight and obesity
respectively, compared to normal weight ­children18. In addition, several studies demonstrated that overweight
school-aged children and adolescents are more exposed to bullying than their normal-weight ­counterparts19,20.
In a US cross-sectional study of 4742 male and 5201 female public school students, associations of weight sta-
tus with social relationships, school experiences, psychological well-being, and some future aspirations were
­observed21. In a recent study in adolescents (12–18 years old), better academic achievements were found among
physically fit as well as normal weight participants compared to unfit and overweight/obese peers, ­respectively22.
Being overweight or underweight increases the risk of somatic and mental health problems, low self-esteem1,23,
and may predispose to bullying, especially in children and adolescents. This, in turn, may lead to poor academic
achievements, psychosomatic and school-related complaints. As such, the identification of school-related fac-
tors associated with body weight status may help to better understand which strategies can be developed to
promote general well-being. To our knowledge, no large-scale study to date has systematically investigated the
link between weight status, psychosomatic complaints and school-related characteristics. With this in mind,
the present study involving 18,462 school-age students from Uppsala County, Sweden aimed to investigate the
relationship between weight status and psychosomatic complaints (PSC) as well as school-related complaints
with a focus on gender differences.

Materials and methods
Participants.  A cohort of 29,106 adolescents aged 12–19 years attending grade 7, 9 and 2nd year of upper
secondary school in the Swedish Uppsala County, were invited to participate anonymously and voluntarily in
the Life and Health Young Cross-sectional Survey, conducted by the Uppsala County Council, Sweden in 2007,
2009, and 2011. The overall response rate was approximately 80 %. From the initial sample size (n = 29,106),
2314 students were excluded because of missing data on sex (n=119), weight, height (n=2145) or inappropriately
high values for BMI (> 50 kg/m2, n=50); 7010 participants ware further excluded because they did not answer
on one or several questions regarding the school-related characteristics. Further, 854 students were excluded
due to missing information on the psychosomatic health complaints. We additionally excluded 466 individuals
for the analysis because of missing covariates. In total, 18,462 participants (51% girls) had no missing values of
measures of interest (including covariates) and were considered eligible for the present analysis.
Written information about the survey was sent to school principals. Adolescents and their legal guardians
were informed about the purpose, content and administration of the survey as well as about its voluntary and
anonymous nature. The survey was filled in during school hours in a test-like situation, i.e. with teachers present
and no possibility to see others’ responses. All adolescents and their legal guardians had the possibility to decline
participation without further explanation. As the students were surveyed anonymously and voluntarily and no
biological material or sensitive personal information was collected, the written informed consent from a student
or legal guardian, as well as ethical approval for the data analysis was not required (Ethical Review Act 2003:460,
the act concerning the Ethical Review of Research Involving Humans, Sweden; Dnr 2012/244). Research was
performed in accordance with relevant guidelines/regulations. The study followed the STROBE checklist.

Assessment of weight status.  Participant’s self-reported weight and height were used for BMI calcula-
tion (kg/m2). The international age- and gender specific BMI thresholds for children, developed by the Interna-
tional Obesity Task Force, were used to categorize subjects as “underweight” (corresponding to BMI of < 18.5 kg/
m2 at age 18 years), “normal weight” (18.50–24.99 kg/m2 at age 18 years) and “overweight/obese” (≥ 25.0 kg/
m2 at age 18 years)24,25. In the present analysis, overweight and obese adolescents were combined into the same
category.

Assessment of psychosomatic complaints (PSC).  The participants were asked how often they had
health complaints during last three months. For this analysis, the following symptoms were used: headache;
stomachache; pain in the back/hips; feeling nervous; difficulty to fall asleep, feeling low; pain in the neck/shoul-
ders; and feeling anxious/worried. These types of complaints have previously been used as health indicators
among school-age children and ­adolescents26–28. Response alternatives were on a 5-point Likert scale: “never”,

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“rarely”, “sometimes”, “often” and “always”. In the analyses with the separate PSCs, each item was dichotomized
as never/ rarely/ sometimes vs often/ always. The scores were also summarized into a PSC index ranging from
0 to 32 points. The 90th percentile (P90) value of the entire sample was equal to 19 and used as a cut-off point
to categorize students as having less complaints (below P90) and having many complaints (at/above P90). The
internal reliability was high (Cronbach’s α = 0.83).

Assessment of school‑related complaints.  In total, nine questions were used to assess school-related
characteristics. Students were asked to choose one of the following alternatives (1) “corresponds exactly”; (2)
“corresponds quite well”; (3) “corresponds to some extent”; (4) “corresponds quite bad”; and (5) “doesn’t cor-
respond at all” to the first three statements if school work is interesting, if the student has friends at school, and if
parents encourage the student to do well at school. Answers were dichotomized as yes (1–3) and no (4–5).
A fourth question was how comfortable the student feels at school with possible answers: (1) “Very comfort-
able”; (2) “pretty comfortable”; (3) “neither comfortable nor uncomfortable”; (4) “quite uncomfortable”; (5)
“very uncomfortable”. Based on the answers, two categories were formed: feeling relatively good at school (1–3)
and feeling bad at school (4–5). A fifth question, academic failure was measured by the question whether the
student has failed any subject at school or not. Possible answers were as follows: (1) “no”, (2) “1–2 subjects”, (3)
“3–4 subjects” or (4) “ ≥ 5 subjects”. Based on the answers, two categories were formed: failed no subject vs. failed
at least one subject at school during the school year. Students were also asked if they play truant with possible
answers on a 6-point scale: (1) “never”; (2) “yes, sometimes during the term”; (3) “yes, once a month”; (4) “yes,
2–3 times a month”; (5) “yes, once a week”; and (6) “yes, several times per week”. The responses were dichoto-
mized as never/seldom (1–2) and play truant once a month or more often (3–6). The students were asked how
often they had been bullied by schoolmates during the term and how often they had bullied others. Possible answers
were: (1) “never”; (2) “yes, once”; and (3) “yes, few times”, which were dichotomized as not being bullied/not
bullying another student(s) (1) and being bullied at school/bullying another student (s) at school (2–3). And
finally, the participants answered the question regarding how they see their future with the answers on a 5-point
scale as follows: (1) “I see my future as very bright”; (2) “I see my future as quite bright”; (3) “I see my future as
neither bright nor dark”; (4) “I see my future as quite dark”; and (5) “I see my future as very dark”. The variable
was classified as “expect to have a bright future” (1–3) and “don’t expect to have a bright future” (4–5).

Assessment of covariates.  Parents’ ethnic background was defined as Swedish (i.e. both parents are born
in Sweden), mixed (i.e. only one parents is born in Sweden), or foreign (i.e. both parents are born abroad) based
on question “where were your parents born?” Family household structure was categorized as living in a household
with both parents vs. single-adult household/other household structure. Parents’ employment status was dichot-
omized as at least one parent was employed vs. unemployed/students/on sick leave/on disability pension/on
parental leave/other. School location was defined either as situated in larger towns and municipalities near large
towns or smaller towns/urban areas and rural municipalities. Year of survey was defined as 2007, 2009 or 2011.

Statistical analysis.  For the statistical analysis, SPSS version 24.0 (SPSS Inc, Chicago, IL) was used. Results
of descriptive analyses are presented as means and standard deviations or numbers and percentages. A binary
logistic regression analysis was utilized to examine the association between weight status (exposure variable)
and the eight separate PSCs, and dichotomized overall PSC score (outcome variables) as well as weight sta-
tus (exposure variable) and the nine school-related complaints (outcome variables). Potential confounders and
intermediate variables were selected based on previously published results of other ­studies8,27 with the help of
directed acyclic ­graphs29.
Multivariable analyses of the associations between weight status and PSCs was performed adjusted for ado-
lescents’ age, parents’ ethnic background, family household structure, parents’ employment status, year of survey
and school location. Two regression models were constructed to study the association between weight status
and school-related complaints: Model A was adjusted for adolescents’ age, parents’ ethnic background, family
household structure, parents’ employment status, year of survey and school location; model B was addition-
ally adjusted for the potential intermediate variable, overall PSC index score. In this analysis, the results based
on Model A were considered as the main findings. The data from boys and girls were analyzed separately and
data from the underweight and overweight/obese adolescents were compared to those of normal-weight. The
Benjamini–Hochberg method was applied to correct for multiple testing of all associations of weight status with
PSC and school-related complaints. P values that passed a critical value corresponding to the False Discovery
Rate (FDR) of 0.05 were considered as strong evidence of associations. For FDR correction, Stata (version 15;
StataCorp, College Station, Texas) was used.

Results
Descriptive data.  A total of 18,462 adolescents (49% boys and 51% girls) from Uppsala County, Sweden
were included into the present analysis. Cohort characteristics, stratified by gender, are shown in Table 1. Being
underweight was more prevalent among girls (11.6%) compared with boys (5%), while the proportion of over-
weight/obese was higher in boys (19.7%) than in girls (10.5%; χ2 = 502.9, df = 2, P < 0.001). The proportion of liv-
ing with both parents was slightly higher in boys (66.5%) than in girls (64.6%, χ2 = 7.8, df = 1, P = 0.005). A higher
proportion of girls (63.8%) studied in larger cities and municipalities near large cities compared with boys (61%;
χ2 = 16.2, df = 1, P < 0.001). Additionally, girls had a higher frequency of PSC than boys (17.5% vs 3.8%, respec-
tively, χ2 = 896.9, df = 1, P < 0.0001) and a larger mean value of the psychosomatic complaints index (girls: 13.2,
boys: 8.7, P < 0.001). No gender differences were found for age, grade, parents’ ethnic background and parents’
employment status. The proportion of PSCs among boys and girls is shown in Table 2. Tables 3 and 4 present

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Boys Girls
Total, n (%) 9078 (49.2) 9384 (50.8)
Age, years (SD) 15.91 (1.53) 15.90 (1.51)
Weight status, n (%)
Underweight 454 (5.0) 1087 (11.6)
Normal-weight 6836 (75.3) 7311 (77.9)
Overweight/obese 1788 (19.7) 986 (10.5)
Grade, n (%)
Grade 7 1340 (14.8) 1359 (14.5)
Grade 9 4077 (44.9) 4165 (44.4)
2 years upper secondary school 3661 (40.3) 3860 (41.1)
Parent’s ethnic background, n (%)
Swedish 7071 (77.9) 7214 (76.9)
Mixed 1029 (11.3) 1107 (11.8)
Foreign 978 (10.8) 1063 (11.3)
Household structure, n (%)
Living with both parents 6040 (66.5) 6060 (64.6)
Another family structure 3038 (33.5) 3324 (35.4)
School location, n (%)
Larger towns and municipalities near large towns 5535 (61.0) 5991 (63.8)
Smaller towns/urban areas and rural municipalities 3543 (39.0) 3393 (36.2)
Parent’s employment, n (%)
At least 1 parent is employed 8808 (97.0) 9069 (96.6)
Unemployed/students/on sick leave/ on disability pension/on parental leave/other 270 (3.0) 315 (3.4)
Psychosomatic complaints, n (%)
Less complaints (below P90) 8730 (96.2) 7741 (82.5)
More complaints (at/above P90) 348 (3.8) 1643 (17.5)
Psychosomatic complaints index, Mean (SD) 8.71 (5.03) 13.17 (5.65)

Table 1.  Socio-demographic characteristics of students included in the analyses. SD standard deviation; P90

90th percentile.

Boys Girls
N = 9078 N = 9384 P-value a
Headache, n (%) 808 (8.9) 2357 (25.1)  < 0.001
Stomach ache, n (%) 628 (6.9) 2130 (22.7)  < 0.001
Pain in the back/hips, n (%) 850 (9.4) 1742 (18.6)  < 0.001
Pain in the neck/shoulders, n (%) 970 (10.7) 2477 (26.4)  < 0.001
Feeling low, n (%) 714 (7.9) 1991 (21.2)  < 0.001
Feeling nervous, n (%) 796 (8.8) 2066 (22.0)  < 0.001
Difficulty to fall asleep, n (%) 1205 (13.3) 2129 (22.7)  < 0.001
Feeling anxious/worried, n (%) 662 (7.3) 2064 (22.0)  < 0.001

Table 2.  Proportion of self-reported psychosomatic complaints (PSC) experienced often or always among

boys and girls. a Chi-square test.

the results of multivariable binary logistic regression analyses between weight status and PSCs, and weight status
and school-related complaints, respectively.

Psychosomatic complaints associated with weight status.  Girls had higher prevalence of all eight
PSC (headache, stomach ache, pain in the back/hips, pain in the neck/shoulders, feeling low, feeling nervous, dif-
ficulty to fall asleep and feeling anxious/worried) than boys (P < 0.0001, Table 2). The most common complaints
among girls were pain in the neck/shoulders (26.4%) and headache (25.1%), whereas for boys it was difficulty
to fall asleep (13.3%), pain in the neck/shoulders (10.7%) and pain in the back/hips (9.4%). After correction
for multiple testing, multivariable analyses controlling for age, parents’ ethnic background, family household
structure, parents’ employment status, year of survey and school location, revealed that underweight boys had
a higher odds ratio for all eight PSC with odds ratios (OR) ranging from 1.44 to 1.84 than normal-weight boys
(Table 3). Overweight/obese boys reported more often headache, pain in the back/hips, and feeling low com-

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Boys Girls
(n = 9078) (n = 9384)
PSC rare, N (%) PSC often, N (%) OR (95%CI) PSC rare, N (%) PSC often, N (%) OR (95%CI)
Headache
Normal-weight 6273 (91.8) 563 (8.2) 1 5514 (75.4) 1797 (24.6) 1
Underweight 393 (86.6) 61 (13.4) 1.75 (1.32–2.33)* 810 (74.5) 277 (25.5) 1.06 (0.91–1.22)
Overweight/obese 1604 (89.7) 184 (10.3) 1.23 (1.03–1.47)* 703 (71.3) 283 (28.7) 1.17 (1.01–1.36)
Stomach ache
Normal-weight 6397 (93.6) 439 (6.4) 1 5677 (77.7) 1634 (22.3) 1
Underweight 405 (89.2) 49 (10.8) 1.79 (1.31–2.45)* 815 (75.0) 272 (25.0) 1.16 (1.00–1.35)
Overweight/obese 1678 (92.2) 140 (7.8) 1.22 (1.00–1.49) 762 (77.3) 224 (22.7) 0.96 (0.82–1.13)
Pain in the back/hips
Normal-weight 6237 (91.2) 599 (8.8) 1 5972 (81.7) 1339 (18.3) 1
Underweight 398 (87.7) 56 (12.3) 1.47 (1.10–1.97)* 896 (82.4) 191 (17.6) 0.96 (0.81–1.13)
Overweight/obese 1593 (89.1) 195 (10.9) 1.24 (1.05–1.47)* 774 (78.5) 212 (21.5) 1.14 (0.97–1.35)
Pain in the neck/shoulders
Normal weight 6134 (89.7) 702 (10.3) 1 5412 (74.0) 1899 (26.0) 1
Underweight 386 (85.0) 68 (15.0) 1.54 (1.17–2.01)* 801 (73.7) 286 (26.3) 1.03 (0.89–1.19)
Overweight/obese 1588 (88.8) 200 (11.2) 1.07 (0.90–1.26) 694 (70.4) 292 (29.6) 1.14 (0.99–1.33)
Feeling low
Normal weight 6343 (92.8) 493 (7.2) 1 5814 (73.5) 1497 (20.5) 1
Underweight 397 (87.4) 57 (12.6) 1.79 (1.33–2.41)* 858 (78.9) 229 (21.1) 1.04 (0.89–1.22)
Overweight/obese 1624 (90.8) 164 (9.2) 1.26 (1.05–1.52)* 721 (73.1) 265 (26.9) 1.37 (1.17–1.60)*
Feeling nervous
Normal weight 6266 (91.7) 570 (8.3) 1 5747 (78.6) 1564 (21.4) 1
Underweight 392 (86.3) 62 (13.7) 1.74 (1.31–2.32)* 826 (76.0) 261 (24.0) 1.16 (1.00–1.35)
Overweight/obese 1624 (90.8) 164 (9.2) 1.05 (0.88–1.27) 745 (75.6) 241 (24.4) 1.15 (0.99–1.35)
Difficulty to fall asleep
Normal weight 5978 (87.4) 858 (12.6) 1 5707 (78.1) 1604 (21.9) 1
Underweight 376 (82.8) 78 (17.2) 1.44 (1.12–1.86)* 822 (75.6) 265 (24.4) 1.15 (0.99–1.34)
Overweight/obese 1519 (85.0) 269 (15.0) 1.19 (1.02–1.38) 726 (73.6) 260 (26.4) 1.21 (1.04–1.42)*
Feeling anxious/worried
Normal weight 6372 (93.2) 464 (6.8) 1 5751 (78.7) 1560 (21.3) 1
Underweight 400 (88.1) 54 (11.9) 1.84 (1.36–2.49)* 845 (77.7) 242 (22.3) 1.06 (0.91–1.24)
Overweight/obese 1644 (91.9) 144 (8.1) 1.14 (0.93–1.39) 724 (73.4) 262 (26.6) 1.26 (1.08–1.48)*

Table 3.  Associations of weight status and self-reported psychosomatic complaints (PSC). Logistic

regression models adjusted for adolescent’s age, parents’ ethnic background, family household structure,
parents’ employment status, school location, and year of survey. PSC rare answer alternatives: never,
seldom, sometimes; PSC often answer alternatives: often, always. CI confidence interval; PSC psychosomatic
complaints. *Associations passed a critical P value corresponding to FDR of 0.05.

pared with normal-weight boys. Underweight girls were more likely to report stomach ache than those of nor-
mal-weight. However, this association did not pass the multiple comparison threshold and no other associations
between underweight among girls and PSCs were observed. Overweight/obese girls had higher odds feeling low,
having difficulty to fall asleep and feeling anxious/worried compared with normal-weight girls (Table 3).
When analyzing the overall PSC index dichotomized as having fewer complaints (below P90) and having
more complaints (at/above P90), our results revealed that underweight boys had higher odds to have more psy-
chosomatic complaints in comparison with normal-weight boys (OR 2.52, 95% CI 1.75–3.63, P < 0.001, passed
FDR correction). A weaker association was observed in underweight girls (OR 1.18, 95% CI 1.00–1.39, P = 0.049,
did not pass FDR correction). Additionally, overweight/obese girls had higher odds to have more psychosomatic
complaints in comparison with normal-weight girls: OR 1.23, 95% CI 1.04–1.45, P < 0.05, passed FDR correction
(P for all BMI*sex interaction < 0.05).

School‑related complaints associated with weight status.  Binary logistic regression analyses
(Model A: adjusted for potential confounders; corrected for multiple testing) revealed that underweight boys
were more likely to report that parents don’t encourage them to do well at school, and had higher odds of aca-
demic failure than normal weight boys (Table  4). The observed association remained significant in model B
(additionally adjusted the overall PSC index score) only for academic failure. Compared with normal-weight,
overweight/obese boys reported more often that they did not feel good at school, truancy, being bullied and

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Boys (n = 9078) Girls (n = 9384)

Model A Model B Model A Model B
OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI)
Academic failure
Underweight 1.44 (1.17–1.78)* 1.37 (1.11–1.69) 1.13 (0.97–1.33) 1.12 (0.96–1.32)
Overweight/obese 1.39 (1.24–1.56)* 1.38 (1.23–1.55) 1.71 (1.47–1.98)* 1.66 (1.42–1.93)
School work is not interesting
Underweight 0.91 (0.72–1.13) 0.83 (0.66–1.05) 1.19(1.03–1.39)* 1.19 (1.02–1.38)
Overweight/obese 0.99 (0.88–1.12) 0.96 (0.85–1.09) 0.98 (0.83–1.15) 0.92 (0.78–1.09)
Have no friends at school
Underweight 1.49 (0.91–2.44) 1.24 (0.75–2.06) 1.41 (0.96–2.07) 1.36 (0.92–2.00)
Overweight/obese 1.26 (0.94–1.69) 1.20 (0.89–1.62) 2.16 (1.54–3.03)* 1.96 (1.39–2.77)
Parents don’t encourage to do well at school
Underweight 1.76 (1.09–2.84)* 1.55 (0.95–2.52) 1.67 (1.21–2.30)* 1.60 (1.16–2.23)
Overweight/obese 1.34 (1.00–1.80) 1.29 (0.96–1.74) 1.66 (1.20–2.29)* 1.52 (1.09–2.11)
Does not feel good at school
Underweight 1.54 (1.05–2.26) 1.19 (0.80–1.78) 1.40 (1.09–1.81)* 1.37 (1.05–1.80)
Overweight/obese 1.49 (1.20–1.86)* 1.40 (1.12–1.75) 1.64 (1.28–2.12)* 1.47 (1.12–1.92)
Play truant once a month or more often
Underweight 1.07 (0.84–1.36) 0.97 (0.76–1.25) 1.02 (0.87–1.20) 1.00 (0.85–1.18)
Overweight/obese 1.23 (1.08–1.40)* 1.20 (1.06–1.37) 1.00 (0.85–1.18) 0.95 (0.80–1.12)
Being bullied at school
Underweight 1.30 (0.99–1.72) 1.12 (0.84–1.50) 1.02 (0.83–1.26) 1.01 (0.82–1.25)
Overweight/obese 1.29 (1.10–1.51)* 1.23 (1.04–1.44) 1.55 (1.28–1.89)* 1.45 (1.19–1.77)
Bullying other student(s) at school
Underweight 0.93 (0.69–1.26) 0.84 (0.62–1.14) 1.24 (0.97–1.60) 1.23 (0.96–1.59)
Overweight/obese 1.29 (1.11–1.50)* 1.25 (1.07–1.46) 1.22 (0.94–1.59) 1.15 (0.88–1.50)
Don’t expect to have a bright future
Underweight 1.46 (0.92–2.32) 1.03 (0.63–1.69) 1.24 (0.89–1.74) 1.15 (0.81–1.63)
Overweight/obese 1.13 (0.85–1.51) 1.03 (0.77–1.38) 1.59 (1.16–2.18)* 1.38 (0.99–1.92)

Table 4.  Associations between weight status and school-related complaints among boys and girls. Normal
weight is used as reference category. Model A: Controlled for adolescent’s age, parents’ ethnic background,
family household structure, parents’ employment status, school location, and year of survey. Model B = Model
A + psychosomatic complaints index. *Associations passed a critical P value corresponding to FDR of 0.05
(Model A only).

bullying others at school, had higher odds of academic failure (Table 4). Underweight girls were more likely to
report that school work is not interesting, to feel that parents don’t encourage them to do well at school, and
not to feel good at school. The same pattern was observed when the model was additionally adjusted for PSC
index (model B; Table 4). Compared with normal-weight girls, overweight/obese girls had higher odds of having
no friends at school, to feel that parents don’t encourage them to do well at school, to not feel good at school,
higher odds of academic failure, of being bullied at school, and not to expect to have a bright future (Table 4).
The observed associations remained significant in the model B except for the variable regarding expectations
about future (Table 4).

Discussion
In the present study, being underweight or overweight/obese was adversely associated with psychosomatic com-
plaints (PSC) and several school-related complaints including social interactions, academic failure, behavioral
and emotional factors. Interestingly, different patterns were observed for boys and girls. In general, girls had a
higher proportion of all psychosomatic complaints than boys. This is in line with several epidemiological stud-
ies which have demonstrated that adolescent girls tend to have higher frequency of psychosomatic symptoms
than ­boys26,30. However, when taking weight status into account, underweight boys had higher odds to have all
psychosomatic complaints than normal-weight counterparts, while no such associations were observed among
underweight girls as compared with normal-weight girls. The link between being overweight/obese (vs normal-
weight) and headache, pain in the back/hips and feeling low were observed among boys, whereas the association
with complaints of feeling low, feeling anxious/worried and difficulty to fall asleep were found among girls.
Additionally, being underweight or overweight/obese was adversely associated with several school-related
complaints. In general, there were more such associations for overweight/obese girls and boys compared with
their normal-weight counterparts, than for the underweight adolescents compared with their normal-weight

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counterparts. Our findings based on a large adolescent cohort, provide additional evidence that weight status
among adolescents may be one of the risk factors for psychosomatic and school-related complaints.

Comparisons with other studies.  Underweight is associated with malnutrition especially in low-income
countries. However, in developed countries, underweight among children and adolescents is becoming a serious
phenomenon that is sometimes underrated in contrast to considerable attention paid to overweight and obe-
sity. Adolescents, especially girls, may experience external social pressure to be thin which in turn may lead to
body dissatisfaction, extensive weight loss and underweight. Moreover, thinness is known to be associated with
variety of adverse mental outcomes such as d ­ epression8, suicidal thoughts and a­ ttempts9, and poorer memory
31
­performance . Results of the present study revealed important gender-specific associations of underweight with
PSC with pronounced link of psychosomatic symptoms among underweight boys than normal-weight counter-
parts.
Studies of associations of weight status and school-related characteristics in adolescents are scarce. A cross-
sectional study of 9943 US adolescents showed that underweight adolescents especially boys had poorer social
relationships and school experiences than their average normal weight ­peers21. In agreement with these results,
the current study demonstrated that underweight adolescents had higher odds to report less parents’ encourage-
ment to do well at school. In addition, underweight boys were more likely to report academic failure whereas
underweight girls had higher odds to report not feeling good at school and that school work is not interesting
compared to normal weight counterparts.
In line with previous findings, our study revealed adverse associations between being overweight/obese and
psychosomatic complaints as well as several school-related complaints. It was previously demonstrated that
overweight or obesity in children and adolescents is often associated with development of psychological distress,
low self-esteem, poor quality of life, discrimination and poorer academic ­performance3,22,32–35. For instance, a
cross-sectional study of school-aged children aged 10 to 17 years showed that obese children had higher odds
to have school problems and grade ­repetition3. In the same study, larger weight was also associated with higher
rates of somatic and psychological disorders including attention deficit/hyperactivity disorder (ADHD), depres-
sion, learning problems, h ­ eadaches3. Our results provide further support to the notion that overweight/obese
(vs. normal-weight) adolescents are more likely to have psychosomatic complaints, such as headache, feeling low
and difficulties to fall asleep than normal-weight counterparts, and emphasize a gender-specific nature of these
associations. The present study also revealed that being overweight/obese among boys and girls was associated
with academic failure and not feeling good at school, which is in line with previous r­ eports3,21,22,34. These factors
may adversely affect social interactions and future aspirations of overweight/obese adolescents. Thus, our find-
ings demonstrated that overweight/obese girls were more likely to report that they do not have friends at school,
parents do not encourage them to do well at school and that they do not expect to have a bright future.
Several studies reported that overweight school- aged children and adolescents are more exposed to bullying
than their normal-weight c­ ounterparts19,20,36 which is consistent with results of the current study. Such a nega-
tive attitude towards overweight and obesity among adolescents may be in large extend explained by anti-fat
stereotypes existing in modern societies. Additionally, results of the present study indicated that overweight/
obese boys were more likely to bully other students at school and play truant from school.
The adverse association between being overweight/obese or underweight and several school-related com-
plaints might be explained by psychological discomfort and poorer general well-being. Psychological problems
such as anxiety, nervousness and mental stress can be associated with increased muscle ­tension37,38, which can
contribute to pain, especially in the neck and ­shoulders38. Subjective psychosomatic complaints are not always
related to a defined diagnosis or ­disease39 but may reflect psychological discomfort and impaired global well-
being in c­ hildhood40. Possible mediation effect of PSC was observed in the current study. Thus, among boys
the association between being underweight and feeling that parents do not encourage to do well at school was
reduced to a non-significant level when adjusted to PSC. Similar pattern was observed among girls on relation-
ship between being overweight/obese and do not expect to have a bright future.
Important strengths of our study are the large sample size and the possibility to adjust for a variety of con-
founders. Several limitations, however, apply to the present study. All measures in the present study were self-
reported. For example, self-reported information on weight and height may lead to under- or over-estimation of
body size. However, inappropriately high and low values for B ­ MI21 were excluded from the analysis. Moreover,
the proportion of underweight and overweight/obese was comparable to findings from previous studies among
children and adolescents in European ­countries41–43. In addition, residual confounding by other factors not
considered in the analysis of the present study (e.g., pubertal status, parents’ education and BMI status) can-
not be excluded. For example, information about menstrual cycle was not available and we do not known if
reports of stomach ache are related to menstruation or not. Additionally, the cross-sectional nature of this study
precludes any assumptions about cause and effect relationships. Thus, it is possible that poor educational and
school-related psychosocial characteristics can lead to emotional stress and, as a consequence, to overeating or
dietary restrictions among adolescents.

Conclusions
In summary, our findings suggest that both underweight and overweight/obesity in adolescents are associated
with higher odds of PSC as well as school-related complaints often in a gender-specific manner. The study
highlights the importance of considering a detrimental impact of abnormal weight status on the psychological
health, school experience and school achievements, which are important constituents of success and confidence
in adult life.

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Data availability
The datasets generated and/or analyzed in this current study are not publicly available based on the data-sharing
agreement with Uppsala County.

Received: 22 January 2021; Accepted: 30 June 2021

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Acknowledgements
We thank Uppsala County Council for kindly providing data from the "Life and Health Young Cross-Sectional
Survey". We would also like to thank Pleunie Hogenkamp for her support.

Author contributions
O.E.T. contributed to the conception and design of the study; O.E.T. performed the statistical analysis and drafted
the manuscript. O.E.T. and S.J.B. performed data interpretation. All authors contributed to the critical revision
of the manuscript for important intellectual content and approved the final version of the manuscript. O.E.T.
had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy
of the data analysis.

Funding
Open access funding provided by Uppsala University. The authors’ work was supported by the Swedish Research
Council (HBS). The funding sources had no role in design of the study, in data collection, analysis, or interpreta-
tion, and no role in writing the article, or in the decision to submit.

Competing interests 
The authors declare no competing interests.

Additional information
Correspondence and requests for materials should be addressed to O.E.T.
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