Annotated Bibliography

338

Middle School to college: iMpact of Weight on Self-eSteeM over tiMe

Etinosa Sharon Oghogho, MPH Florida International University

Helen W. Bland, PhD Georgia Southern University

Obesity rates among children and young adults are considered one of the most consequential global public health challenges of the 21st cen- tury (Hurt et al., 2010; WHO, 2016). Obesity comorbidities include propensity of low self-esteem (Franklin et al, 2006). Using the Theory of Planned Behavior (TPB), a triangulation mixed-methods, quasi-ex- perimental research design was implemented among college students who reported weight, height, and self-esteem both currently and ret- rospectively for middle school. Randomized cluster sampling method was utilized (n=185). Calculated BMI indicated 25.2% of participants were overweight or obese in middle school, which increased to 45.1% in college. Contrary to calculated BMI, 78.2% of participants de- scribed themselves as normal/underweight in middle school (n=140) and 69.1% in college (n=125). Current BMI was positively associated with middle school weight concerns and middle school BMI (p=0.01), and negatively associated with middle school self-esteem (p<0.05). Subjective norm construct of TPB was most influential predictor of behavior. Thematic content analysis to qualitative inquiry of “if you could tell your middle school self one thing about your weight, what would you say?” indicated affirmation themes of “love the skin you’re in” and admonition themes of “stay active” and “portion control”. Study implications for Generation Z are explored.

Key words: obesity, self-esteem, health, college students

Background Obesity is a major public health concern

(Hurt, Kulisek, Buchanan, & McClave, 2010). According to the National Health and Nutrition Examination Survey (NHANES), more than two-thirds of adults were consid- ered to be overweight or obese, with one-third of these obese (Flegal, Carroll, Kit, & Ogden,

2012). Comorbidities that accompany over- weightness and obesity include high blood pressure, stroke, CVD, diabetes, cancer, osteoarthritis, and respiratory complications (CDC, 2015a). Obesity is directly responsible for over 300,000 deaths annually and leads to a 50% increase in the risk of death from all causes (Mokdad, Marks, Stroup, & Gerberd- ing, 2005).

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Childhood Obesity WHO has declared obesity among chil-

dren an epidemic (WHO, 2003). In the United States, more than one third (31.7%) of chil- dren between the ages of 2 to 19 years were overweight, 16.9% were obese, and 11.9% were severely obese (Ogden, Caroll, Curtin, Lamb & Flegal, 2010). Most overweight chil- dren end up being overweight adults (WHO, 2016). Lee et al (2017) reported that if cur- rent childhood obesity trends continue, it will cost the U.S. economy $8.1 billion in direct medical costs and $13.8 billion in lost produc- tivity by the year 2020. Combating childhood obesity is primary prevention in deterrence of adult obesity.

Primary factors most responsible for childhood obesity include behavioral, genet- ics, and environmental (Loos, Vimaleswarm, & Wareham, 2007). Common behavioral factors consist of physical activity levels, dietary patterns, and medication usage (CDC, 2015a). Genetic factors include family history of obesity, adipose storage type, and metabo- lism rate (Silventoinen, Rokholm, Kaprio, & Sorenson, 2010; Gest, Tseng & Kahn, 2007). Environmental factors comprise of lack of appealing and safe places to be active, limited access to healthy affordable foods, greater availability of high energy dense foods, sug- ary/ sweetened beverages, and increasing portion sizes (CDC, 2015b).

Numerous studies have substantiated the impact of physical inactivity on childhood obesity (Sekine et al., 2002; Tremblay & Willms, 2003; Roblin, 2007). CDC (2015c) recommends 60 minutes or more of daily physical activity for children. The Youth Risk Behavioral Survey of 2013 (CDC, 2015c) found only 29% of all high school students reported meeting the 60 minute daily physical activity requirement. In non-school hours, nearly two-thirds of children are not involved in organized sports and 25% report no physical activity (Westat, Huhman, & Heitzler, 2003).

Sedentary lifestyle is frequently accompa- nied by excessive television, video gaming, and screen time (Hinckley, Salmon, Okely, Crwaford, & Hesketh, 2012). A recent study determined that most children between ages 8-18 years old experience an average of about 4.5 hours of screen time daily (Hinkley et al., 2012; Robinson, 2001). Mitchell et al., (2013) demonstrated increased screen time is signifi- cantly correlated with rises in BMI.

Obesity Among College Students Evidence corroborated by various studies

depict trends of substantial weight gain among college freshmen, accompanied by gradual but continuous weight gain across time at college (Leone, Morgan, & Lundy, 2015; Vella-Zarb & Elgar, 2009; Gores, 2008). Sira & Pawlak (2010) conducted a cross-sectional study that examined rates of overweightness and obesity (BMI 25) among college students that found 21.3% and 10.8% of the college students were overweight and obese, respectively. Peltzer et al. (2014) examined prevalence of overweight/obesity among a random sample of college students, similar findings indicated 22% of college students were overweight or obese (24.7% women and 19.3% men).

Obesity and Self-Esteem Although obesity is measured in physical

parameters, emotional and social impacts on obese individuals, especially children, can persist over time (Sahoo et al., 2015). Psychosocial effects associated with child- hood obesity include social isolation, peer problems, and low self-esteem (Dietz, 1998; Strauss, 2000). While several studies have linked childhood obesity to low self-esteem in children and adolescents (Strauss, 2000; Hesketh et al, 2004; O’Dea, 2006), other studies affirm that obesity actually precedes low self-esteem in many children thus sug- gesting a causal relationship (Hesketh et al., 2004; Strauss 2000). Obese children with low

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self-esteem report remarkable higher rates of unhappiness, apprehensiveness, and seclusion (Strauss, 2000).

Low self-esteem during adolescence has been linked to poor long-term outcomes such as lower educational attainment, higher rates of joblessness, and more financial hardship (Waddell, 2006, Wang & Veugelers, 2008; Trzesniewski, Donnella, & Moffitt, 2006). Factors associated with low self-esteem in- cludes depression, anxiety, unhealthy eating patterns, early initiation of sexual activity among females, and use of illicit drugs (Mann, Hosman, Schaalma & deVries, 2004; Wang & Veugelers, 2008; Spencer, Zimet, Asiasma & Orr, 2002; Strauss, 2000). Characteristics associated with low self-esteem impact the growth and transitional process of an adoles- cent into an adult.

Perception of one’s physical appearance has consistently found to be the main predic- tor of self-esteem across the lifespan (Ata, Ludden, & Lally, 2006). An association be- tween an individual’s body image and self-es- teem has been confirmed by several studies (Davidson & McCabe, 2006; Huebscher, 2010). Body image is linked to self-esteem, interpersonal confidence, and eating and ex- ercise behaviors (Huang et al., 2007). Poor body image and self-esteem have hindered social skills advancement and building con- fident relationship with others (Davidson & McCabe 2006). Overweight individuals are prone to depression, poor body perception and low self-esteem (Sjoberg, Nilsson, & Leppert, 2005; Erermis et al., 2004).

Theory of Planned Behavior The Theory of Planned Behavior (TPB)

(Ajzen & Fishbein, 1975) addresses individ- ual motivational factors as determinants of the intention to perform a particular behavior (Glanz, Rimer, & Viswanath, 2008). Accord- ing to TPB model, behavioral intention is determined by attitude towards the behavior,

social norms, and the perception of one’s ability to change their behavior (Glanz et al., 2008). Various effective behavior change interventions have been developed due to diverse application of the TPB to weight control (Gastil, 2000; Jemmott & Jemmott, 2000). Gronhoj, Bech-Larsen, Chan, and Tsang (2013) used the TPB to predict healthy eating in adolescents. Conner, Martin, and Silverdale (1996) reported that those who have good body esteem and were comfortable with their bodies tend not to engage in dieting. The researchers of this study utilized the TPB constructs of attitude, subjective norms, and perceived behavioral control to assess partic- ipants’ beliefs about outcomes or attributes of performing a behavior in relation to obesity.

Purpose of the Study Purpose of this triangulation mixed-meth-

ods quasi-experimental research study was to determine the impact of past middle school BMI and self-esteem on current college-aged BMI and self-esteem. Using the Theory of Planned Behavior, participating college students were asked to retrospectively re- port their weight perception and self-esteem both at middle school age and in the present (n=185). Sampling methodology employed was randomized cluster design using self-re- port to focus on the constructs of attitude, subjective norms, and behavioral control. Furthermore, qualitative inquiry illuminated certain aspects of the participants’ perceptions on weight and self-esteem across time.

Methods Research Design

Research methodology employed for this study was triangulation mixed-methods, qua- si-experimental, cross-sectional design. The purpose of triangulation research is to explore different yet complimentary data (Creswell, 2014). This research design is considered

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cross-sectional as participants gave input at a single point in time, responding to both quantitative and qualitative inquires simul- taneously (Kumar, 2014). An advantage to cross-sectional studies include the ability to measure relationships between variables (Creswell, 2014).

Measures Obesity

Obesity is defined as an irregular or ex- cessive buildup of fat that may hinder health (WHO, 2003). The statistical tool used to calculate obesity and overweightness is the Body Mass Index (BMI). BMI corresponds with the amount of body fat for most people (CDC, 2015a). An adult who has a BMI be- tween 25 and 29.9 is considered overweight, while a BMI of 30 or higher is considered obese (CDC, 2015a). Among children, a BMI at or above the 85th percentile and low- er than the 95th percentile is referred to as overweight, while obesity is having a BMI at or above the 95th percentile (CDC, 2015a). Self-reported height and weights, both at middle school age and currently, allowed for the researchers to calculate individual BMI across time for each participant.

Body Self-Esteem Questionnaire Established instruments were utilized with

adaptations to fit the specific purpose of this study (Spencer, 2003). The final instrument consisted of three subscales: weight concern (10 items), exercise/sports encouragement (5 items), and body self-esteem (22 items). A three-item response option to the subscales were “not at all”, “a little” or “a lot”. Partici- pants recalled their middle school experience when responding to the questions. Original Cronbach alpha subscales ranged between 0.66 to 0.91, indicating good internal consis- tency reliability (Spencer, 2003). Internal con- sistency for this study was strong for the three

subscales, with Cronbach alpha scores for weight concern (α=0.698), encouraged to ex- ercise/play sports (α=0.662), and body self-es- teem (α=0.891). Cronbach alpha scores higher than 0.60 indicated strong internal consistency reliability (McDermott & Sarvela, 1999).

Demographic questions included height and weight (current and middle school) as well as gender, ethnicity, race, and age. Additional questions explored descriptions of current and middle school weight and self-esteem. A qual- itative, open-ended question “if you could tell your middle school self one message about your weight or self-esteem, what would you say?” completed the instrument.

Sampling Methodology Population of the study consisted of

college students at a midsized, rural, south- eastern university enrolled in a course during summer 2016. Participants were selected by probability, cluster sample design where in- tact classrooms were randomly selected from all classes offered. Given the population of the school, with fixed effect size and alpha level set, 20 courses among eight colleges at the university were selected. Participants were required to be 18 years of age or older. Randomization insured that participants were of diverse disciplines and programs across the university. This study was approved by the university’s Institutional Review Board prior to implementation.

Data Collection Procedures Faculty members of aforementioned

randomly selected courses were contacted via email for their permission to distribute surveys to students. Eleven out of 20 faculty members consented, representing graduate and undergraduate levels. Students were in- structed not to write any identifiable markers to ensure anonymity. Informed consent prac- tices were adhered to. A total of 185 students participated in the study.

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Data Analysis Frequencies and percentiles were utilized

for descriptive statistics among variables and demographics. BMI was analyzed both as a categorical and continuous variable. Pearson product moment correlational coefficients determined relationships between variables. Data were analyzed using SPSS software (IBM SPSS, 2016). Qualitative data anal- yses included thematic content analysis of open-ended responses.

Results Participants

Majority of the participants were female (n=118, 63.8%) (Table 1). Caucasians rep- resented a little over half of the participants (n=100, 54.1%), while African-Americans were the second largest racial group (n=60, 32.4%). Age representation was split equally among the three age groups of 18-20, 21-23, and > 24 years old. The mean self-reported middle school BMI was 22.5 (87-92 percen- tile) (overweight category) and college age BMI was 26.05 (overweight).

BMI in Middle School and College Descriptive statistics of self-reported

and actual BMI are delineated in Table 2. In middle school, 21.1% (n=31) reported being overweight or obese, while 25.2% (n=37) were actually overweight or obese. In college, the discrepancy becomes larger with only 30.9% (n=56) of the students reported that they were overweight or obese, while 46.1% (n=82) actually were overweight or obese. When participants were asked if their weight impacted their self-esteem in middle school, 31.9% (n=59) answered yes which increased to 51.9% (n =95) of college students answer- ing in the affirmative.

Table 1. Frequency and percentiles of demographic characteristics of study participants (n=185).

Categorical Variables SD n % Continuous Variables x SD

Gender (n=181) Middle School BMI 22.50 5.36

Female 118 63.8

Male 63 34.1 Current BMI 26.05 5.70

Race (n=178) Age 24.13 5.88

African-American 60 32.4

Caucasian 100 54.1

Asian 8 4.3

Multiracial 2 1.1

Other 8 4.3

Age (n=180)

18-20 yrs 55 30.6

21-23 yrs 63 35.0

> 24 yrs 62 34.4

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Correlation of Past/Present BMI and Self-Esteem

Variables explored for this study included college BMI, middle school BMI, weight concerns in middle school, encouraged to play sports/exercise in middle school, and middle school body self-esteem (Table 3). Measure of the variables were continuous and met the criteria for normal distribution, thus Pearson product moment correlations were utilized to ascertain associations (Morgan, Leech, Gloeckner & Barrett, 2013). Self-es- teem was significantly correlated with all variables measured (p<0.05). The strongest positive correlation for self-esteem was if one was encouraged to play sports/exercise mid- dle school (r =0 .202, p =0.008). The more students in middle school were encouraged to exercise and play sports by relevant others (subjective norm), the more likely they were to have higher self-esteem. Significant nega- tive correlations were found between self-es- teem in middle school and middle school

BMI (r = -0.401, p =0.001) and middle school weight concerns (r = -0.551, p =0.001). As middle school BMI increased, or weight con- cerns increased, that self-esteem decreased significantly. Lastly, there was a significant positive correlation between middle school BMI and college BMI (r = 0.535, p =.001), indicating that if one is overweight or obese in middle school this is very likely to continue in college.

Qualitative Assessment Participants were asked the qualitative,

open ended question “If you could tell your middle school self one thing about your weight, what would you say?”. Thematic content analyses led to identification of four major themes: affirmation, admonishment, acceptance and perception changes (Figure 1). The majority of participants, 78.3% (n=145), answered this question. Among 145 respon- dents, only 9.0% (n=13) replied with a nega- tive, or what was themed as “admonishment”

Table 2. Contrasts between BMI, weight description and self-esteem in middle school and currently by frequency and percentiles (n=185).

Variable n % Variable n %

Middle School Current

Actual BMI (n=147) Actual BMI (n=178)

Underweight 31 21.1 Underweight 5 2.8

Normal 79 53.7 Normal 91 51.1

Overweight 27 18.4 Overweight 40 22.5

Obese 10 6.8 Obese 42 23.6

Self-Reported BMI (n=179) Self-Reported BMI (n=181)

Underweight 20 11.2 Underweight 3 1.7

Normal 120 67.0 Normal 122 67.4

Overweight 36 19.5 Overweight 48 26.5

Obese 3 1.6 Obese 8 4.4

Weight Impacted Self-Esteem (n=183) Weight Impacted Self-Esteem (n=183)

Yes 59 31.9 Yes 95 51.9

No 124 67.0 No 88 47.6

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statement. Participants wanted their younger selves to know that weight would take on less importance as they got older, that life was more than what you weighed.

Findings indicated that the average middle school age child is overweight, and this con- tinues in young adulthood. Participants tend- ed to view themselves as thinner as they actu- ally were, both in middle school and college.

Table 3. Intercorrelations, Means and Standard Deviations for Five Variables (n=185).

Variable 1 2 3 4 5 M SD

1. College BMI — .54** .35** -.10 -.18* 26.1 5.7

2. Middle School BMI — — .48** -.15 -.40** 22.5 5.4

3. Weight Concern MS — — — -.14 -.55** 17.6 3.3

4. Encouraged Exercise MS — — — — .20** 11.7 2.1

5. Self-Esteem MS — — — — — 49.8 9.8

*p<0.05; ** p<0.01

Figure 1. Thematic Content Analysis of “If you could tell your middle school self one thing about your weight or self-esteem, what would you say?” (n=145).

Theme Direct Quotes

Affirmation Do not listen to others, listen to myself.

You look great!!

Rock on! Life is too short to obsess about weight. Be Happy in your own skin!

Stay healthy and exercise for you, not for others to accept you!

You are on the right track.

Remember that you have to put yourself out there to be memorable. I know you are going through a lot be brave and strong.

Admonishment Portion control.

Exercise and eat healthier.

Don’t drink soda or eat carbs that often.

Be more confident.

Acceptance You are not fat! You are just right!

You are normal. Enjoy your life. Do good in this world.

Perception changes Don’t worry, looks stop mattering so much after college.

It won’t matter in the end.

Do not worry about what you like for your weight because in the end it does not matter.

No one will remember what you look liked in middle school. It’s about having fun and finding yourself through sports and peers.

These views were supported by the thematic content analysis, with 91% of participants’ responses positive about their current weight. Higher BMI at middle school was significant- ly correlated with lower self-esteem, higher weight concerns, and lower encouragement to exercise/play sports (p< 0.05). Implications of results will be explored in the discussion section.

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Theory to Practice Theory of Planned Behavior links one’s

beliefs and behavior (Ajzen & Fishbe- in,1975). The concept states that attitude toward behavior, subjective norms, and perceived behavioral control will together shape an individual’s behavioral intentions and actual behaviors. In this study, each of these constructs were measured to determine impact. Subjective norms construct proved to be most influential on weight, self-esteem and weight reducing behaviors.

Attitude Toward Behavior Attitude towards a behavior is the extent

to which performance of the behavior is believed to have positive or negative worth (Ajzen & Fishbein, 1975). This construct was measured using weight concerns ques- tions such as: “how important was it that you were thin in middle school; did you ever try to lose weight when in middle school; and were you ever on a diet in middle school’. Participants reported that although some of them tried to lose weight when in middle school, more reported that they were okay with how they looked. This is understand- able, for as a middle schooler, one cannot discern livelong impact of being obese or health benefits of keeping a healthy weight. Surprisingly, positive self-affirmation in- creased among college students, irrespective of increased health knowledge acquisition.

Subjective Norms This study demonstrated that students with

higher self-esteem and lower weight were the ones motivated to engage in exercise and sporty activities by significant others. Subjec- tive norms refer to the belief of the approval/ disapproval of an individual’s behavior by others of importance, such as peers or fam- ily members. In this study, subjective norm was measured with the following questions

(among others): “were you ever encouraged to exercise or play sports in middle school; how often did you exercise or play sport with your parents when in middle school; and I thought my parents liked my look when I was in middle school.” Findings depicted that middle school students were more likely to have higher self-esteem and lower weight, the more they were encouraged to exercise and engage in sports by significant others. Subjective norm was found to be important in maintenance of healthy weight and higher self-esteem.

Perceived Control Perceived control reveals the level to

which an individual think that a situation controllable (the extent to which perfor- mance is up to the individual) and self‐effi- cacy (how easy or difficult it is to perform a behavior) (Ajzen & Fishbein, 1975). This concept was measured by questions such as: “how important was it to you to be heavier in middle school; when I was in middle school, I wish I looked better; and when I was in middle school, I felt ashamed about how I looked.” Individuals who feel they have control over their behaviors are more likely to change a behavior that leads to better health outcomes (Conner et al., 1996). Perceived control and self-efficacy is vital for weight loss or weight reduction behaviors to occur.

The results of the study determined that weight status of an individual does not only depend on behavioral lifestyles and physical activity patterns, but also determined by the relationships of influential other. Especial- ly during childhood, weight, self-esteem and weight-reducing behaviors are greatly influenced by significant others as parents, guardians, and teachers as suggested by the construct of subjective norms in the Theory of Planned Behavior.

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Strengths and Limitations Several limitations exist in this study. His-

torically, self-reported heights and weights are under-reported (Strommel & Schoenborn, 2009). Retrospective recollection of middle school height and weight could have con- tributed to inaccuracies and introduced recall bias. Even so, overall calculations of BMI using these self-report data gave calculated BMI values consistent with national averag- es. A second limitation of this study is the use of a cross sectional study design which does not take temporality into consideration (Hen- nekens & Buring, 1987). Lastly, researchers did not inquire how participants thought their weight status affected their self-esteem. Thus, researchers were not able to tell the reason- ing and phenomenon behind the associations from the students’ perspectives.

Discussion and Conclusions This study sought to determine the effect

of past middle school BMI and self-esteem on current college aged BMI and self-esteem at a southeastern university utilizing the Theory of Planned Behavior. Findings from this study confirmed previous studies on weight and self-esteem with startlingly new insights.

Weight Gain Congruent with previous studies, U.S.

children and young adults are heavier, with nearly half of those under 18 overweight or obese (Ogden et al., 2010) and two-thirds of the adult population overweight or obese (Ogden, Carroll, Kit & Flegal, 2014). For the first time in United States history, the substantial rise in obesity could decrease life expectancy at birth for the current generation, meaning that children born today could lead shorter lives than their parents (Olshansky et al., 2005).

Students who are overweight or obese in middle school are likely to remain so in

college and across the lifespan. A recent research letter published in the Journal of American Medical Association (JAMA) by Snook et al. (2017) reported two major findings: (1) being heavier is now socially acceptable and (2) fewer adults are trying to lose weight. Adults who have attempted to lose weight several times without attainment of their goals are less likely to continue trying (Snook et al., 2017). Results from this study are consistent with aforementioned JAMA findings, the majority of the participants are confident about their current weight irrespec- tive of being overweight or obese. Adults tend to underestimate the BMI weight category that they fall into, with the higher BMI clas- sifications having the greater error (Strommel & Schoenborn, 2009). Underestimation of BMI is accompanied by underestimation of health risks associated with obesity, with co-morbidities occurring later in life decreas- ing susceptibility of immediate risk. Impact of the obesity trends among children could be significant loss of quality and quantity of healthy lifespan.

Self –Esteem Study participants included members

from both the Millennial generation (born 1981-1996), as well as Generation Z (born 1997+). This is noteworthy, since these two generations have common traits but also are remarkably different. These differences impact all aspects of life, including self-es- teem. Millennials have been characterized as over-structured, perfectionists, and high achievers (Bland, Melton, Welle & Bigham, 2012). These characteristics can lead to high stress, emotional exhaustion, and low self-esteem (Bland et al., 2013). Generation Z, or referred to as the iGeneration, have rejected many of the characteristics of their parents. Major characteristics of Generation Z (pertinent to this study) include that they are: more risk adverse; limited in capacity for

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self-regulation (need for immediate gratifica- tion) due to consistent technology use; against challenging themselves to be perfect, accept- ing of self and others, and health conscious (ORA, 2018). These characteristics translated towards a health perspective reveal that iG- eneration believe in “live for today”, will not be bullied into body shaming or self-loathing, and exist comfortably in their own skin. Al- though this new reality will impact self-es- teem positively, one could ascertain that this could aggravate the obesity problem.

Implications Findings from this study underscore the

necessity to repackage healthy weight mes- saging for the iGeneration. Threats of health co-morbidities and death sometime in the future do not resonate with Millennials or Generation Z. Health promotion fear cam- paigns and scare tactics continue to prove to be ineffective. Cognitive acquisition is not sufficient for health behavior change. Instead, alternative motivations to adopt healthy be- haviors that impact healthy weight and life- style choices need to be explored.

According to the results of this study, em- phasis on the constructs of subjective norms (via positive self-affirmation, influential oth- ers) could positively impact healthy weight

and self-esteem. Subjective norms that dictate appropriate motivations to lose weight should include: emphasis on making friends, build- ing a supportive network, feeling better, and experiencing less stress. The role of health professionals would be to build awareness and implement programs for influential oth- ers (peers, parents, guardians, teachers, coun- selors, etc.) on how relationships potentially affect children’s healthy weight and self-es- teem, both positively or negatively. Children and adolescents whose influential others believe in them and provide encouragement, have the tendency to have higher self-esteem and feel greater motivation in maintenance of a healthy weight.

Health professionals, in collaboration with influential others, can be at the intersection of healthy weight and positive self-esteem. Together they can create awareness, offer reinforcement, and serve as advocates for supportive personal interactions, policies, and programs. What we, as influential others, say and do actually does impact healthy weight and self-esteem over time.

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