Toll like receptors in Chronic Lymphocytic Leukaemia

Dietary patterns, body image perception and obesity in female adolescents

Introduction The rise in child and adolescent obesity is a global concern. Current figures reveal an increase in overweight and obese children in developed countries of approximately 7% since 1980, with the United Kingdom being the 9th most prevalent (PHE, 2016a). In England alone 28% of children are overweight and obese (NHS Digital, 2016) with a higher proportion in adolescents (PHE, 2016c). Obesity is associated with numerous health complications in adults such as: cancer, type 2 diabetes (T2D) and cardiovascular disease (CVD) (Pi- Sunyer, 2009) as well as increasing the risk of death (Solomon, and Manson, 1997). However, T2D, hypertension and sleep apnoea among others are becoming prevalent in adolescents due to the increasing trend of obesity (Ebbeling, Pawlak and Ludwig, 2002). Furthermore, if a child is obese they have a higher probability of becoming an obese adult (Serdula, Ivery and Coates et al., 1993) particularly if they are still obese in adolescence, (Guo and Chumlea, 1999) thus promoting the opportunity to develop additional comorbidities. Whilst several factors contribute to this epidemic, the underlying principle of obesity is understood through the concept of energy balance. This denotes a person’s body weight is unchanged as energy intake (food and drink consumption) and energy expenditure (basal metabolic rate, thermogenesis and physical activity) are equal (Spiegelman and Flier, 2001). However, if an imbalance occurs whereby energy intake is more than energy expended, the additional energy is stored and a positive energy balance is inevitable (Hill, Wyatt and Peters, 2012), thus the individual gains weight. This literature review will discuss the relationship between dietary patterns of female adolescents and body image perceptions in contributing to obesity. Dietary Habits in Adolescence Adolescence marks the stage between childhood and adulthood whereby major physiological and psychological changes occur such as: physical and sexual development, body composition and enhanced cognitive and social development. Optimal nutrient requirements, including energy, are essential to facilitate this growth. Nevertheless, the environment makes this difficult as less nutritious foods that are more satisfying are made easily accessible (Neumark-Sztainer et al., 1999) at low economic costs (Drewnowski and Darmon, 2005). Extensive literature suggests that adolescents consume energy dense foods (Phillips et al., 2004) and soft drinks (Johnson and Frary, 2001) that ironically contain “empty calories” (Reedy and Krebs-Smith, 2010). These foods lack beneficial nutrients such as vitamins and minerals and are processed with high amounts of sugar, fat and/or salt which increases energy consumption through calories. A preference for these foods is at the expense of nutrient rich foods such as: wholegrains and vegetables (Nelson et al., 2007), with only 8% of adolescents consuming the recommended amount of fruits and vegetables per day (Public Health England, 2016b). A 10-year

longitudinal study involving adolescent females showed that those who followed a diet predominately rich in vegetables, fruits and grains resulted in a lower waist circumference than those whose diet included less nutritious desserts, confectionary and other snack-type foods (Ritchie et al., 2007). This study therefore demonstrates the importance of consuming fruits and vegetables in preventing obesity. In addition to the common food choices of adolescents, eating patterns are also associated with the prevalence of obesity. Snacking in adolescence has become a central part of the diet with an approximate 20% increase from around 1970 (Sebastian, Goldman and Enns, 2010). The preferred snacks are typically processed foods and confectionary (Anderson, Macintyre and West, 1994), thus low in nutrient quality as previously discussed. Conversely, many studies show that an increase in snack consumption does not lead to an increase in BMI (Field et al., 2004), yet among other studies there has been a positive association between obesity and drinks high in sugar (Malik, Schulze and Hu, 2006). A study by Keast, Nicklas and O’Neil (2010) shows that increased snack consumption has an inverse relationship with obesity due to lower BMI and waist circumference values among female subjects. A possible explanation is that the 24-hour dietary recall method that was used, is associated with underreporting energy values (Johansson et al., 2001). This is supported by Poppitt et al’s (1998) finding where regardless of weight status, females underreported energy intake from snacks. Additionally, adolescents who are more likely to snack, skip meals more frequently (Savige et al., 2007), particularly missing breakfast (Brooks et al., 2015). This eating behaviour is more prevalent in females and they are twice as likely to skip breakfast than males (Brooks et al., 2015). Studies have shown a relationship between those who consume breakfast with having a lower BMI than those who do not (Gleason and Dodd, 2009). Thus although snacking may have a positive outcome, it should not be used to replace meals as this may increase the risk of obesity. Body Image Perceptions Body image perception is critical in adolescence as individuals become more aware of their evolving physical characteristics (Christie and Viner, 2005). Adolescents may exert feelings of body dissatisfaction whereby they are unhappy with their body size or they may distort their own body image with an unrealistic estimation of their perceived body size (Pesa, Syre and Jones, 2000). Both of these aspects reflect a negative body image perception that is most common in females (Skemp-Arlt, 2006). This dissatisfaction has been an on-going trend due to the impact that the media has on adolescent’s desire to become thinner (Groesz, Levine and Murnen, 2001). With technology becoming increasingly available, a study by Tiggemann and Slater (2013) has shown a significant difference between adolescent females who spend more time on the Internet and use Facebook with the desire to be thinner than those who did not. Additionally negative body image in females’ increases with age as 26% of 11 years olds and 50% of 15 year olds believe they are “too fat” (Brooks et al., 2015). Unrealistic ‘thin’ imagery is contrary to the actual body changes that occur during adolescence. Throughout puberty

females acquire more body fat than boys (Siervogel et al., 2003), which is predominately stored in the hip region forming a ‘curved’ figure typical of a fully developed woman (Ross et al., 2014), but this is not typically preferred. Siegela et al (1999) showed that body dissatisfaction was highest in females who began puberty early, suggesting that physical changes in body composition are not desirable. Furthermore, Neumark-Sztainer et al (2002) showed that overweight females were more dissatisfied with their bodies than those of ‘normal’ weight. Nevertheless, whilst body weight estimation was fairly accurate, still 30% of ‘normal’ weight females thought they were overweight. Body Image Perceptions and Dietary Patterns Body image perceptions (distortion and dissatisfaction) are associated with eating patterns in adolescents (Skemp-Arlt, 2006). Numerous studies have shown a relationship between negative body image and unhealthy eating patterns, which may lead to eating disorders (Stice and Shaw, 2002) and obesity. Adult’s eating patterns are generally formed based on those in adolescence, thus positive eating patterns should begin in adolescence (Ross et al., 2014). As previously discussed, particularly evident in female adolescents is the desire to have a thin body (Groesz, Levine and Murnen, 2001). Consequently, many females feel insecure about their weight status and will attempt to manage their weight themselves, with one quarter of 15 year olds currently trying to lose weight (Brooks et al., 2015). Dieting is a common method of attempted weight loss in adolescence; nevertheless a study by Vander Wal and Thelen (2000) revealed that dieting is significantly higher in girls than boys and more significant if the girls were obese. In agreement with Neumark- Sztainer et al’s (2002) theory, the obese girls were least happy with their body weight explaining their desire to diet. There were similar findings in an additional study with a large number of subjects (1370 adolescents). Girls with an increased body weight and lower body satisfaction were more likely to restrict eating and/or overeat (Mäkinen et al., 2012). Whilst the primary goal of dieting is to lose weight, it is evident that overeating will have the opposite effect- weight gain (Haines and Neumark-Sztainer, 2006). Studies have shown that females who have attempted to lose weight are also inclined to ‘binge’ eat (Neumark-Sztainer et al., 1998). Binge eating is again associated with body dissatisfaction, as those who resort to this increased food consumption may do so as a result of not gaining their ideal body weight. A study has shown a correlation between girls who ate breakfast regularly and snacked more frequently with having a lower body weight that those who did not (Bibiloni et al., 2013), supporting Gleason and Dodd’s (2009) findings. However, energy consumption differed among the cohort as overweight girls consumed less energy from food overall, because they were more likely to snack often and skip full meals. It is important to mention that the overweight girls were unhappy with their body size, thus being the reason for their dietary choices (choosing snacks rather than meals) and therefore little energy intake. Whilst this study did not specifically assess patterns of weight

management, this energy restriction may have been due to the adolescents’ attempting to lose weight (Skemp-Arlt, 2006). An additional study confirms that adolescents are more likely to attempt to lose weight when they are unhappy with their physical body appearance (Nowaka, 1998), which in turn has an impact on their food choices. Females who were attempting to lose weight at the time of the study consumed less fat-type foods such as: ice cream, cakes and chocolate, thus portraying healthy weight loss attempts. Nevertheless, this is still associated with an attempt to restrict calories due to less frequent meals being consumed and no significant increase in healthier foods like fruits and vegetables. Another study reported similar findings among overweight females. Those with a higher BMI and most dissatisfied with their body weight generally consumed less chocolate, biscuits and other fat containing foods, but with an additional increase in fruits and vegetables than those of an average weight (Bibiloni et al., 2013). This study is evidence that low body satisfaction in overweight females has a more positive effect on eating habits than average weight females attempting to lose weight. An additional longitudinal study assessed adolescent’s eating habits in relation to body dissatisfaction over 5 years (Neumark-Sztainer et al., 2006). This study showed that regardless of weight status, adolescents with low body satisfaction engage in behaviours shown to be unhealthy, including dieting and binge eating. On the contrary, they also sought the highest amount of healthy ways to control weight status. Far from a contradiction, these results are more demonstrative of the fluctuations in adolescent’s dietary behaviours over time. The need to tackle body dissatisfaction still stands, which in turn will avoid the likelihood of adolescents taking drastic measures to control their weight. Nevertheless a final study by Sonneville et al (2012) has demonstrated the importance of high body satisfaction with better eating habits over time. The study involved a cohort of obese female adolescents whose eating habits and body image satisfaction were assessed and followed up after 11 years. Findings show that individuals who were most happy with their body size at the start of the study had lost more weight than those least satisfied, demonstrating that increased body satisfaction is preventative against obesity. Conclusion In conclusion, adolescent obesity and several other associated health complications have become increasingly prevalent. Although obesity is complex with many factors contributing to it, this literature review has primarily focussed on the relationship between adolescent’s eating patterns in relation to body image perception. In adolescence these elements are a major concern, as the greatest changes in both aspects are present at this time period and are likely to continue into adulthood. Unhealthy dietary patterns have shown to be associated with negative body image perceptions in numerous studies- predominantly in females. Negative feelings are not only evident in overweight females but also those of a ‘normal’ weight due to distorted image perception. Modern day pressure from the internet and on social media to be thinner is a major factor in forming a negative body image, with unhealthy dietary patterns as an additional consequence. In addition, these unhealthy eating patterns such as meal skipping, binge eating and low

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