RESEARCH ARTICLE
Weight Status Misperception as Related to Selected Health Risk Behaviors Among Middle School Students BRIAN C. MARTIN, PhD, MBAa WILLIAM T. DALTON, III PhDb STACEY L. WILLIAMS, PhDc DEBORAH L. SLAWSON, PhD, RD, LDNd MICHAEL S. DUNN, PhD, MPHe REBECCA JOHNS-WOMMACK, EdDf
ABSTRACT BACKGROUND: Weight misperception has been documented among children although the impact on health risk behaviors is less understood, particularly among middle school students. The goals of this study were to describe sociodemographic differences in actual and perceived weight, correspondence between actual and perceived weight, and weight-related health risk behaviors, as well as to examine weight misperception and interactions with sociodemographic variables in explaining weight-related health risk behaviors. METHODS: Participants were recruited at 11 public school districts participating in the Tennessee Coordinated School Health (CSH) pilot program. A total of 10,273 middle school students completed the Centers for Disease Control and Prevention’s Youth Risk Behavior Survey administered by teachers in the school setting. RESULTS: Findings revealed sociodemographic differences in actual and perceived weight as well as weight misperception. Although overestimating one’s weight was significantly related to greater likelihood of weight-related health risk behaviors, significant interactions showed this relationship to be especially pronounced in females. Additional distinctions based on sociodemographic variables are indicated. CONCLUSIONS: Results highlight the importance of screening for health risk behaviors including weight misperception among middle school students. The CSH program offers an opportunity to understand health risk behaviors among students while also informing and evaluating methods for intervention. Keywords: health risk behavior; middle school students; obesity; weight misperception. Citation: Martin BC, Dalton WT III, Williams SL, Slawson DL, Dunn MS, Johns-Wommack R. Weight status misperception as related to selected health risk behaviors among middle school students. J Sch Health. 2014; 84: 116-123. Received on March 7, 2012 Accepted on November 26, 2012
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he United States has seen an increase in the prevalence of overweight and obesity over the past 30 years that currently remains high in both adult and child/adolescent popultions.1-3 The prevalence for overweight and obesity among the pediatric populations increased from approximately 15% in the 1980s to more than 30% by 2004,3,4 and 31.8% were overweight or obese in 2009 to 2010.2 The economic consequences of an obese society are staggering. Medical cost estimates for obesity in the adult population were as high as $78.5 billion in 1998, increased $40 billion through 2006, and were estimated to be $147 billion in 2008.5 Annual medical costs for obese children were $2.9 billion per year more
than costs for normal and underweight children due to increased prescription drugs, emergency department utilization, and outpatient expenditures in 2002 to 2005. These costs were in addition to obesityassociated hospitalization costs, approximately $237.6 million in 2005.6 The majority of states with high obesity rates are in the south. From 2008 to 2010, Tennessee (TN) was one of 12 states with adult obesity rates above 30%, and one of 9 states with childhood obesity rates greater than 20%.7 In 2007, almost 21% of TN children aged 10 to 17 years were obese (#6 national ranking) and slightly less than 30% of children aged 6 to 17 years engaged in physical activity on
a Associate Professor, MPH Coordinator, (
[email protected]), Department of Health Services Management and Policy, East Tennessee State University, P.O. Box 70264, Johnson City,
TN 37614. bAssistant Professor, (
[email protected]), Department of Psychology, East Tennessee State University, P.O. Box 70649, Johnson City, TN 37614. c Assistant Professor, (
[email protected]), Department of Psychology, East Tennessee State University, P.O. Box 70649, Johnson City, TN 37614.
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a daily basis. Rural areas have been associated with higher rates of pediatric obesity8 and poor health behaviors.9 In addition to the measurable prevalence of overweight and obese youth, there is a significant segment of the population who maintain a perception of being overweight or obese. Western cultural pressure to be thin is believed to contribute to nonoverweight adolescents perceiving themselves as overweight, thereby leading to engagement in weight change behaviors.10,11 This perception is more related to body dissatisfaction than to actual body size, but puts social pressure on adolescents, particularly girls, to maintain an ‘‘ideal’’ body weight.11-13 Therefore, girls are more likely to compare their body type to the culturally accepted body image of being thin, which is typically below average for weight. One study found weight status perception predicted weight loss intent more than actual body fat.14 Whether overweight/obese status is actual or perceived, a large percentage of adolescents engage in weight loss behaviors. For instance, approximately 36% of normal weight high school students report engaging in weight-loss activities.15 Attempts to lose weight do not always result in healthier diets or recommended participation in physical activity.16 In fact, some dieting behaviors are potentially deadly (eg, laxatives, diet pills, fasting, vomiting), and are markers for depressed mood and eating disorders.12 In addition, research has found body dissatisfaction correlates with risk factors for eating disorders17 as well as psychosocial disorders.18 Efforts have begun to identify the frequency and effect of weight misperception. Boys and girls contrast in the manner they overestimate or underestimate their weight, with approximately 60% of adolescent boys accurately perceiving their weight compared to 50% of adolescent girls in 1 study18 and one-third of boys misrepresenting their weight versus one-quarter of girls in another study.19 Other studies have found as many as 1 in 3 overweight adolescents underreport their weight4 and 16% of normal weight high school students perceive themselves as overweight.15 A recent study assessing high school students suggested accurate perception may be important for overweight and obese adolescents to engage in weight control practices.20
Limited research has examined the relationship between weight misperception and health risk behaviors, especially among middle school students. One study examined a sample of overweight adolescents and found those with accurate weight perception reported greater engagement in healthy weight management strategies such as trying to maintain or lose weight, exercise, and/or eat less for weight control.4 When adolescents participate in risky health behaviors such as unhealthy eating habits and insufficient physical activity, they may be putting themselves at risk for immediate and lifelong medical, mental, and social problems.2,11,12 Further understanding of the link between weight misperception and weight-related health behaviors may inform prevention/intervention efforts. The goals of this study were (1) to examine sociodemographic differences in actual weight, perceived weight, and the correspondence between actual and perceived weight; (2) to examine the sociodemographic differences in weight-related health risk behaviors; and (3) to examine the predictive value of weight misperception and the interaction of weight misperception with sociodemographic factors in explaining health risk behavior in a sample of middle school students participating in the Coordinated School Health (CSH) pilot program in TN. We hypothesized greater weight misperception would be found in girls as compared to boys and those children who misperceived their weight, especially girls and those misperceiving themselves as overweight or obese, would be more likely to engage in health risk behaviors.
METHODS The Centers for Disease Control and Prevention’s (CDC) Youth Risk Behavior Survey (YRBS) was used in this study. The YRBS is designed to determine health risk behaviors of middle school students21 and measures demographics, height and weight, unintentional injury, tobacco use, drug/alcohol use, sexual risk taking, weight control, and physical activity. Participants All 11,046 middle school students (6th to 8th grade, approximately 12 to 14 years) attending 11 public
dAssistant Professor, (
[email protected]), Department of Community and Behavioral Health, East Tennessee State University, P.O. Box 70674, Johnson City, TN 37614. e Associate Professor, (
[email protected]), Department of Health Promotion, Coastal Carolina University, P.O. Box 261954, Conway, SC 29528. f Executive Director, (
[email protected]), Tennessee Department of Education, Office of CoordinatedSchool Health, 710 James RobertsonParkway, AndrewJohnson Tower, 6th Floor, Nashville, TN 37243.
Address correspondence to: Brian C. Martin, Associate Professor, MPH Coordinator, (
[email protected]), Department of Health Services Management and Policy, East Tennessee State University, P.O. Box 70264, Johnson City, TN 37614. The authors would like to thank Amal Khoury, PhD, William S. Frye, BS, and Brittany Williams, MPH, for assistance with preparing the manuscript. Everyone who contributed significantly to this work has been listed.
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school districts in TN were invited to take part in the YRBS. The schools were selected based on their participation in a CSH pilot program in TN. The 11 school districts represented diversity throughout TN—5 districts were located in west TN, 3 districts were located in middle TN, and 3 districts were located in east TN. All students in the 11 selected schools districts were eligible to participate.
percentile) categories. We refer to self-reported weight as actual weight. Perceived weight. Perceived weight was determined using a self-reported item which asked respondents to self-identify whether they were very underweight, slightly underweight, about the right weight, slightly overweight, and very overweight. The response categories were collapsed from 5 to 3 categories prior to analysis. Very overweight and very underweight were collapsed within overweight and underweight, respectively. This was due to the fact that very overweight and very underweight participants had low responses, less than 5% and 2%, respectively. Previous research has similarly collapsed weight perception categories.19 Weight misperception. Weight misperception was assessed by determining the correspondence between actual and perceived weight status. Respondents were categorized as having an ‘‘adequate or correct’’ view of their weight if their perceived status matched with their actual weight. They were categorized as ‘‘underestimating’’ or ‘‘overestimating’’ their weight if they perceived their weight to be lower or greater than their actual weight, respectively. Such categorization of weight misperception has been used in prior research.18,19 Weight-related health risk behaviors. Weightrelated health risk behaviors were assessed using 6 items from the YRBS. Five items used a dichotomous response scale of yes or no and one item used a specific response option that was further dichotomized based on the Expert Committee’s recommendations regarding television viewing.23
Procedure Data collection took place during April and May of 2008 at participating schools. Prior to administering the questionnaire, a consent process comprised of passive parental consent with oversight by each school district’s CSH Coordinator and school administrator was implemented by each school. Teachers familiar with the administration protocol were responsible for administering the survey to their students during class. These teachers collected the completed questionnaires and mailed them directly to a third-party data management company whose personnel electronically scanned the survey forms and created a data set without student identifiers. This data set was then returned to researchers for analysis. The response rate was 93%, based on the number of students who did not complete the survey due to not having parental permission, refusing to participate, or being absent on the day the survey was administered. Measures Demographics. Information collected about respondents included sex, region, age, grade level, and race. Region was categorized as less or more rural based on the county of the school categorized using the United States Department of Agriculture Economic Research Service Rural-urban Continuum Codes (RUUC) (http:// www.ers.usda.gov/Briefing/Rurality/RuralUrbCon/), with 1 to 3 representative of ‘‘less rural’’ and above 3 indicating ‘‘more rural.’’ Dummy variables were created for the 3 grade levels and for racial/ethnic categories of white, black, Hispanic, and Other (comprised of Asian, American Indian, and Pacific Islander). Self-reported weight. Self-reported weight was determined using self-reported height and weight. Body mass index (BMI; kg/m2 ) was calculated using ® a SAS macro provided by the CDC that took into account sex, age in months, weight in kilograms, and height in centimeters. This application used sex- and age-specific 2000 CDC growth charts22 to assign participants to underweight (sex-specific BMI-for-age < 5th percentile), healthy weight (sexspecific BMI-for-age 5th to