Self-reported weight perceptions, dieting behavior, and breakfast eating among high school adolescents.
Adolescence, a time of great change and uncertainty with the onset of puberty, is often accompanied by preoccupation with body size and shape among youth. Average weight gain is approximately 31 lb (14 kg) for females and 33 lb (15 kg) for males, (1) with differences in body shape and size between the sexes evident. Although body dissatisfaction and issues occur more often in females, recent evidence suggests that males are increasingly concerned with body weight as well. (2-5) Ironically, while anxiety about body weight remains an issue, including stereotypes about body weight, (6) the US population has become the most obese in the world. (7)In 2000, 15.5% of adolescents (ages 12-19 years) were overweight, while an additional 14.9% of adolescents were at risk for being overweight (body mass index [BMI] for age between the 85th and 95th percentile). (8) Thompson et al (9) suggested powerful sociocultural forces, such as family, peers, and media, contribute to body language, body image, and eating disorders in American culture. As a consequence, discontent with one's body continues to cause insufficient nutritional intake when there are feelings of social vulnerability and intense self-consciousness. (10)
Common dietary practices used for weight control are reducing food intake, skipping meals, and fasting. Some adolescents may reduce their food intake or skip meals altogether, especially breakfast. In a recent study of 700 ninth graders in Louisiana who completed a 24-hour recall of dietary intake, both girls (23%) and boys (14%) skipped breakfast. Overall, results showed that 19% of the students skipped breakfast. (11) Skipping meals is detrimental because only 2% of school-aged children currently meet the recommended minimum number of servings for all 5 major food groups in the Food Guide Pyramid. (12) Nutritionists recommend that one third of daily calories should be eaten for breakfast, so missing or deliberately skipping breakfast will compromise health, energy levels, and cognitive performance. (13)
Breakfast consumption may vary by gender, particularly those with poor body image and/or weight preoccupation. A study to determine prevalence of breakfast consumption, physical activity, and smoking among secondary school students in an Ontario (Canada) community found that 48.8% of boys and 36.1% of girls ate breakfast daily. Furthermore, 63.9% of girls were concerned about their body weight compared to 36.1% of the boys. Among girls concerned about body weight, a larger proportion was more likely to skip breakfast compared to those who were not concerned. (14)
Societal pressures often influence females more than males to be more concerned about their weight, resulting in a higher prevalence of distorted body image and more stringent weight-control goals. Paxton et al (15) examined the factors of weight-control behavior among public high school students in South Carolina by finding race and gender differences in BMI, body weight self-perception, weight-management goals and practices. However, even though gender and ethnic differences have been documented for body shape, body image, and weight control, (16-18) little research has investigated the role of breakfast eating in the context of unhealthy weight management. Breakfast makes important contributions to American adolescents' dietary intakes such as calcium, (19) and much effort has been expended on improving breakfast composition in our schools. (20) However, such efforts may not have the intended impact if students are choosing to bypass breakfast altogether, owing to an unhealthy preoccupation with body weight and engagement in extreme dieting practices. Therefore, the purpose of this study was to investigate the relationships between body weight perceptions, dieting behaviors, and breakfast eating among adolescents.
METHODS
The Youth Risk Behavior Survey (YRBS), distributed in South Carolina, was used for this exploratory analysis. The YRBS used a sampling procedure designed to obtain a representative sample (with the exception of special education schools) of all high school students in grades 9-12. The YRBS has established adequate reliability. (21) The Youth Risk Behavior Surveillance System focuses on 6 major areas of adolescent behaviors: those that lead to intentional and unintentional injuries, tobacco, alcohol and other drug use, sexual behaviors, dietary behaviors, and physical inactivity. (22)
Schools were randomly selected using a systematic basis for each enrollment size category, by using PCSAMPLE, a computerized sampling program, which narrowed the 241 eligible schools to 71 schools in 87 districts, statewide. The 241 schools were stratified into 3 enrollment categories: schools with 74 to 874 students were classified as small, schools with enrollments from 875 to 1278 were classified as medium, and schools of more than 1279 students were classified as large. Our data include 58 of the 71 eligible schools (82% response rate) with 4597 usable questionnaires from 5563 sampled students (83% response rate) for an overall response rate of 68% (82 x 83%). These weighted results can be used to make important references concerning the priority health risk behaviors of regular public high school students in grades 9-12.
Classes that met during second period were eligible for classroom level sampling selection to maximize student eligibility. Using random starts, classes were selected with systematic equal probability sampling. When the number of students selected by PCSAMPLE was substantially less than expected, class samples were increased by the same systematic sampling of additional classes. The desired number of participants (n = 125) was met by most schools. The survey was anonymous in that no personal identification was recorded. A school and class code was used for Centers for Disease Control and Prevention reporting purposes. Parent notification forms were distributed at least 5 days in advance of survey administration; those parents who did not want their children to participate were required to return the form. Survey administrations were conducted by trained data collectors, emphasizing anonymity, privacy, and confidentiality. This research was approved by the host university's review board for the rights of human subjects in research.
Data Analysis
The analyses were conducted separately for the 4 race and gender groups, white females (WF), black females (BF), white males (WM), and black males (BM). The use of indicator or dummy variables to represent the 4 groups (WE BF, WM, BM) would have assumed that the coefficients of all risk and confounding variables were constant across all 4 race and gender groups. Because this assumption was false, the 4 groups were analyzed separately.
The dependent variable for this study asked students "During the past 5 school days, where did you mostly eat breakfast?". The 5 response options were "no breakfast past 5 days"; "breakfast in cafeteria most"; "breakfast at home most"; and "ate, but not at home, school." These responses were collapsed and dichotomized into "yes, I ate breakfast" and "no, I did not eat breakfast" for our analyses with those who ate breakfast serving as the referent group. Multiple logistic regression was conducted using SAS-callable Survey Data Analysis (SUDAAN) (23) at [alpha] = .05. SUDAAN takes into account the weighting as well as the clustering within schools and classes nested within schools. Adjusted odds ratios (OR) and confidence intervals were calculated to determine which weight perception and dietary behaviors were associated with those who did not eat breakfast, for each race and gender group. Variables that did not meet the .05 significance level were not retained in the model. All students who did not answer questions used in the regression procedure were excluded from the analysis by numerical procedures of SAS/ SUDAAN.
The independent variables explored in this study were as follows: self-perceptions of weight (overweight/underweight), current weight goal (trying to lose/gain weight), dieted to lose weight (past 30 days), fasted to lose weight (past 30 days), took diet pills to lose weight (past 30 days), and vomited or took laxatives to lose weight (past 30 days) (Table 1). Adolescents were categorized as having reported the behavior or not, with the referent group designated as those who did not report any of the dieting behaviors, those who reported perceptions of being at the right weight, and those who reported wanting to remain at their current weight. SAS/SUDAAN automatically deleted any incomplete record. Frequencies and percentages for all study variables are presented in Table 1 by race and gender.
RESULTS
Description of Subjects
The total number of subjects who participated in the 1999 YRBS was 4597. However, only 4175 valid observations were available for this analysis owing to (a) non-response by subjects to the variables of interest, (b) responses that could not be read via optical scanning, (c) out-of-range responses, and (d) exclusion of subjects who reported their race as "other" than black or white (n = 383, 9.2%). Failure to answer any variable of interest also resulted in deletion (n = 163, 3.9%). Of the survey participants, 2257 (54.0%) were female and 1918 (46.0%) were male. White females accounted for the largest population (29.0%), followed by white males (25.2%), black females (25.1%), and black males (20.8%). Approximately 31% (n = 1302) of the study population was in 9th grade, followed by 10th (n=962, 23%), 11th (n=985, 23.6%), and 12th (n 910, 21.8%) grade students. Sixteen students (0.4%) did not indicate their grade. Only 10 (0.2%) students in the sample were [less than or equal to] 13 years of age; most students (n= 3598, 86.2%) were between 14 and 17 years of age, and 567 students (13.6%) were 18 years or older.
Association Between Not Eating Breakfast, Weight Perceptions, and Dieting Behaviors
White Females. Significant associations were established between not eating breakfast (past 5 days) and self-perceptions of overweight (OR = 1.44), dieted to lose weight (OR= 1.40), fasted to lose weight (OR = 2.97), and vomited or took laxatives to lose weight (OR = 1.76) for white females (Table2). White adolescent females who reported inappropriate dieting behaviors and negative weight perceptions increased the odds of reporting not eating breakfast between 1.4 and 2.97 times when compared to those white females who did not report these dieting behaviors and negative weight perception variables.
Black Females. Only 1 significant relationship was established between not eating breakfast (past 5 days) and fasted to lose weight (OR = 1.77) for black females (Table 2). Black adolescent females increased the odds of reporting not eating breakfast 1.77 times if they reported fasting to lose weight in comparison to those black females who reported not fasting to lose weight.
White Males. Significant associations were established between not eating breakfast (past 5 days) and 5 variables: self-perceptions as overweight (OR = 1.47), trying to lose weight (OR = 1.43), eating fewer calories to lose weight (OR = 1.38), fasted to lose weight (OR = 2.14), and took diet pills to lose weight (OR = 2.40) for white males (Table 2). However, 1 significant protective association was also detected for trying to gain weight (OR = 0.74) and not eating breakfast (past 5 days). Thus, white adolescent males who reported inappropriate eating behaviors and negative weight perceptions increased the odds of reporting not eating breakfast between 1.38 and 2.40 times when compared to those white males who did not report these dieting and weight perception variables. However, white males who reported trying to gain weight significantly decreased their odds of reporting not eating breakfast (past 5 days).
Black Males. Significant relationships were established between not eating breakfast (past 5 days) and 5 variables: self-perceptions as overweight (OR = 1.61), trying to lose weight (1.72), eating fewer calories to lose weight (OR = 1.49), fasted to lose weight (OR = 1.71), and took diet pills to lose weight (OR = 2.31) for black males (Table2). However, similar to white males, 1 significant protective association was detected for trying to gain weight (OR = 0.71) and not eating breakfast (past 5 days) for black males as well. Thus, black adolescent males who reported inappropriate eating behaviors and negative weight perceptions increased the odds of reporting not eating breakfast between 1.49 and 2.31 times when compared to those black males who did not report these dieting and weight perception variables. In addition, black males who reported trying to gain weight significantly decreased their odds of reporting not eating breakfast (past 5 days). These significant relationships mirrored white males in this study.
DISCUSSION
This study demonstrated the ability of 1 nonintrusive item to reveal problematic weight perceptions and inappropriate dietary practices among a large, stratified random sample of adolescents in South Carolina. Results suggest that a substantial number of public high school adolescents are reporting not eating breakfast on an average school day. Approximately 42% (n = 1742) of our study sample reported not eating breakfast during the past 5 school days. Although recent research suggests lower socioeconomic status children and adolescents are more likely to skip breakfast, (24) this phenomenon cannot fully explain this study's findings.
Study results suggest that a substantial number of public high school students in South Carolina are experiencing negative weight perceptions and practicing inappropriate dieting behaviors. More than one half of the participants (n=2272) reported perceptions of being overweight compared to 23% of adolescents perceiving themselves overweight in a study by Brener et al. (25) Study findings also revealed that approximately 41% of adolescents (n = 1706) were trying to lose weight at the time of this study, which is consistent with Paxton et al (15) who reported on 41.7% of high school students trying to lose weight. With a large portion of the sample believing they are overweight and actually trying to lose weight, it is important to consider dieting behaviors reported in this study. Thirty-seven percent (n = 1554) of students reported eating fewer calories to lose weight in the past 30 days, while 25% of the sample (n = 1126) admitted to inappropriate dietary practices such as fasting, taking diet pills or laxatives, and vomiting.
This study also demonstrated the importance of distinguishing between gender and race as moderators of the relationships between eating breakfast, weight perceptions, and dieting behaviors. For example, this study suggests that eating breakfast and some inappropriate dieting behaviors and negative weight perceptions were more prevalent among white females, white males, and black males, although black females reported only fasting to lose weight as significantly related to not eating breakfast. However, fasting to lose weight was also significantly associated with not eating breakfast for all race and gender groups. Compromised nutritional intake during formative years and fasting for weight loss, while normative, are not benign behaviors, (26) with problems ranging from acute self-consciousness to debilitating eating disorders.
An additional, significant protective association was also detected among males, but not for females, who reported trying to gain weight. Males who reported trying to gain weight were significantly less likely to skip breakfast. This may reflect the fact that males believe they need to increase their energy intake to gain weight (most likely muscle mass) for greater social acceptance and self-esteem (27,28) for the same reasons females engage in extreme dieting practices to manage weight.
The association between not eating breakfast and negative perceptions of body weight (males and white females), trying to lose weight (males and white females), eating fewer calories to lose weight (males), fasting to lose weight (males and females), taking diet pills to lose weight (males), and vomiting or taking laxatives to lose weight (white females) for adolescents may be explained in part by national trends in the United States. (29) For example, a national survey of 8th- and 10th-grade students in the United States found that 32% skipped meals, 22% fasted, 7% used diet pills, 5% induced vomiting after meals, and 3% used laxatives to lose weight. (30) Thus, adolescents who engaged in poor dietary practices with poor weight perceptions may be more likely to skip breakfast (and possibly other meals) to control weight. Some suggest that fear of fatness and recurrent dieting are more than risk factors, actually representing the earlier stages of an eating disorder, at least for some people. (31)
Although it is difficult to determine from this cross-sectional study, it is possible that some of the adolescents have started the process of developing an eating disorder. It is not uncommon for eating disorders to begin in early adolescence, with greater than 90% of reported eating disorders occurring among females. (9,32,33) Students in this study who reported not eating breakfast, having poor perceptions of body weight, and practicing improper dieting behavior could be suffering from anorexia nervosa or bulimia nervosa. These eating disorders may cause serious mental and emotional complications and possibly mortality. (17)
Study limitations should be noted here. First, the use of a cross-sectional study design precludes determination of the temporal sequence of breakfast eating and body weight perceptions. Second, this study may reflect only youth in South Carolina and may not be nationally representative. Third, interpretations made in this study are limited to high school students completing a survey using a self-report protocol in public schools. Finally, the logistic regression analyses (SAS/SUDAAN) called for the elimination of subjects with missing data on the variables of interest. Therefore, observed associations are likely to be conservative (ie, an underestimate of the magnitude of the reported associations).
CONCLUSIONS
Despite the stated limitations, our study demonstrated an important association between self-reported breakfast eating, weight perceptions, and dieting behaviors among high school students. Although efforts to encourage adolescents to eat breakfast have increased, (34) it appears that many students may not be taking full advantage of school breakfast programs (or breakfast in general), owing to, perhaps, an unhealthy preoccupation with weight and drastic weight-loss behaviors. Of students who reported eating breakfast, only 13% (n = 557) of students reported eating breakfast in the school cafeteria.
Previous research among Australian youth would suggest that skipping breakfast is a matter of choice for most youth (eg, lack of time, lack of sleep, not hungry) as opposed to socioeconomic status as has been suggested in the United States. (35,36) However, although speculative, our results suggest that adolescents may be skipping breakfast as part of a patterned lifestyle of unhealthy weight management. Whatever the case, nutritional problems, among others, lie beneath many learning problems, as hunger affects adolescents' concentration and ultimately their ability to learn, (37,38) and these poor nutritional habits may manifest themselves as early as 10 years of age. (27)
Based on these findings, it seems unlikely that efforts to encourage youth to eat breakfast will ameliorate all the dietary challenges facing today's adolescents, as these unhealthy weight perceptions and dietary practices reach beyond the scope of increased breakfast offerings. However, several recommendations are offered. First, health educators, teachers, and other human-service personnel who work with youth should discuss the prevalence and ramifications of skipping meals, specifically breakfast. Second, by engaging students in more comprehensive programming to affect students' body image, eating attitudes, and behaviors, (10,28) lasting changes in self-image and lifestyle may result. As part of this comprehensive programming over several years, not just in a 1-semester high school health course, problematic students could be identified and assisted through referral to health personnel knowledgeable about adolescent development. Health professionals could query students with several key questions in a nonjudgmental style. For example, students could be asked, "How much would you like to weigh?", "How do you feel about your weight?", and "Are you or anyone close to you worried about your eating behavior?". Observed student distress about weight and food concerns should heighten concern, and referral is advised. (1) Finally, additional research seems warranted to better understand why students are skipping breakfast and to determine if skipping breakfast is a possible indicator of disordered eating among gender and racial groups.
References
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(33.) Beals KA, Manore MM. The prevalence and consequences of subclinical eating disorders in female athletes. Int J Sport Nutr. 1994;4: 175-195.
(34.) Burghardt JA, Gordon AR, Fraker TM. Meals offered in the National School Lunch Program and the School Breakfast Program. Am J Clin Nutr. 1995;61(suppl 1):187S-198S.
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(36.) Shaw ME. Adolescent breakfast skipping: an Australian study. Adolescence. 1998;33(132):851-861.
(37.) Costante C. Healthy learners: the link between health and student achievement. Am Sch Board J. 2002;January: 1-3.
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Keith Zullig, MSPH, PhD, Assistant Professor, ([email protected]): Valerie A. Ubbes, PhD, CHES, Associate Professor, (Ubbesva@muohio. edu); and Jennifer Pyle, MS, Research Associate, (jennifer_pyle@yahoo. com), Physical Education, Health, & Sport Studies, Miami University, Oxford, OH 45056; and Robert F. Valois, PhD, MPH, FASHA, FAAHB, Professor, ([email protected]), Health Promotion, Education, & Behavior, Family & Preventive Medicine, Schools of Public Health and Medicine, University of South Carolina, Columbia, SC 29208. This research was funded by Cooperative Agreement #U63/CCU 802750-04, US Centers for Disease Control & Prevention, National Center for Disease Prevention and Health Promotion, Division of Adolescent and School Health, Atlanta, Georgia and Cooperative Agreements with the South Carolina Department of Education.
Table 1
Weight Perceptions and Dieting Behavior Variables by Race and
Gender:Frequency (n) and Weighted Percent (%)
White Females Black Females
Risk Variable (1208), n (%) (1049), n (%)
Self-perceptions of weight
About the right weight 449 (37.2) 335 (31.9)
Overweight 615 (50.9) 554 (52.8)
Underweight 144 (11.9) 160 (15.2)
Current weight goal
Stay the same weight 449 (37.2) 372 (35.5)
Trying to lose weight 706 (58.4) 508 (48.4)
Trying to gain weight 53 (4.4) 169 (16.1)
Dieted to lose weight
(past 30 days)
Yes 699 (57.9) 404 (38.5)
No 509 (42.1) 645 (61.5)
Fasted to lose weight
(past 30 days)
Yes 228 (18.9) 150 (14.3)
No 980 (81.1) 899 (85.7)
Took diet pills to lose weight
(past 30 days)
Yes 136 (11.3) 65 (6.2)
No 1072 (88.7) 984 (93.8)
Vomited or took laxatives to lose
weight (past 30 days)
Yes 94 (7.9) 68 (6.5)
No 1114 (92.2) 981 (93.5)
Ate breakfast, past 5 school days
Yes 674 (55.8) 557 (53.1)
No 534 (44.2) 492 (46.9)
White Males Black Males
Risk Variable (1051), n (%) (867), n (%)
Self-perceptions of weight
About the right weight 254 (24.1) 151 (17.4)
Overweight 597 (56.8) 506 (58.4)
Underweight 200 (19.1) 210 (24.2)
Current weight goal
Stay the same weight 504 (48.0) 327 (37.7)
Trying to lose weight 261 (24.8) 231 (26.7)
Trying to gain weight 286 (27.2) 309 (35.6)
Dieted to lose weight
(past 30 days)
Yes 248 (23.6) 203 (23.4)
No 803 (76.4) 664 (76.6)
Fasted to lose weight
(past 30 days)
Yes 76 (7.2) 110 (12.7)
No 975 (92.8) 757 (87.3)
Took diet pills to lose weight
(past 30 days)
Yes 48 (4.6) 64 (7.4)
No 1003 (95.4) 803 (92.6)
Vomited or took laxatives to lose
weight (past 30 days)
Yes 26 (2.5) 61 (7.0)
No 1025 (97.5) 806 (93.0)
Ate breakfast, past 5 school days
Yes 685 (65.2) 517 (59.6)
No 366 (34.8) 350 (40.4)
Table 2
Associated Perceptions of Weight and Dieting Behaviors and
Not Eating Breakfast by Race and Gender
Odds Ratio and 95% Confidence Interval
Dieting Behavior White Female Black Female
Self-perceived as
slightly/very
underweight 0.94 (0.73-1.21) 1.14 (0.80-1.63)
Self-perceived as
slightly/very
overweight 1.44 *** (1.19-1.73) 1.12 (0.82-1.52)
Trying to gain weight 0.52 (0.26-1.05) 1.05 (0.78-1.41)
Trying to lose weight 1.40 ** (1.12-1.75) 1.22 (0.96-1.57)
Dieted to lose weight
(past 30 days) 1.15 (0.89-1.49) 1.27 (0.94-1.72)
Fasted to lose weight
(past 30 days) 2.97 *** (1.95-4.54) 1.77 ** (1.12-2.79)
Took diet pills to lose
weight (past 30 days) 1.33 (0.98-1.80) 2.04 (0.97-4.30)
Vomited or took laxatives
to lose weight (past
30 days) 1.76 ** (1.20-2.58) 1.32 (0.71-2.44)
Odds Ratio and 95% Confidence Interval
Dieting Behavior White Male Black Male
Self-perceived as
slightly/very
underweight 0.79 (0.58-1.09) 1.08 (0.83-1.40)
Self-perceived as
slightly/very
overweight 1.47 * (1.02-2.13) 1.61 ** (1.11-2.32)
Trying to gain weight 0.74 * (0.55-0.98) 0.71 * (0.50-0.97)
Trying to lose weight 1.43 * (1.02-2.02) 1.72 ** (1.16-2.56)
Dieted to lose weight
(past 30 days) 1.38 * (1.03-1.90) 1.49 ** (1.11-2.01)
Fasted to lose weight
(past 30 days) 2.14 ** (1.28-3.56) 1.71 ** (1.11-2.60)
Took diet pills to lose
weight (past 30 days) 2.40 ** (1.32-4.37) 2.31 ** (1.24-4.31)
Vomited or took laxatives
to lose weight (past
30 days) 1.37 (0.65-2.89) 1.38 (0.88-2.16)
* p < .05; ** p < .01; *** p < .001.
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| Author: | Zullig, Keith; Ubbes, Valerie A.; Pyle, Jennifer; Valois, Robert F. |
|---|---|
| Publication: | Journal of School Health |
| Geographic Code: | 1USA |
| Date: | Mar 1, 2006 |
| Words: | 5043 |
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