C 2006) Journal of Clinical Psychology in Medical Settings, Vol. 13, No. 3, September 2006 ( DOI: 10.1007/s10880-006-9029-4
Self-Esteem, Teasing and Quality of Life: African American Adolescent Girls Participating in a Family-Based Pediatric Overweight Intervention1 Marilyn Stern,2,3,5 Suzanne E. Mazzeo,2,3 Jerlym Porter,2 Clarice Gerke,2 Daphne Bryan,4 and Joseph Laver3 Published online: 17 June 2006
Two studies investigated overweight in African American girls. First, African American adolescent girls (BMI was ≥ 85th percentile) and their mothers participated in focus groups addressing weight and eating. Although mothers and daughters shared some similar views on these issues, there were important discrepancies, with mothers expressing greater doubt about the potential success of a healthy weight program. The second study evaluated baseline data from 39 African American girls participating in a weight management program; mothers’ reports were also analyzed. In both studies, adolescents reported significant teasing, and in the second study, teasing was inversely associated with social quality of life (β = .55, t = 3.01, p = .007). Motivation to participate was positively associated with teasing (r = .50, p < .01). Self-esteem was inversely related to positive health habits (all p < .05). Mothers who viewed their daughters as having higher self-esteem were less concerned about their daughters’ weight. Differences in mothers’ and daughters’ perceptions highlight the importance of a family approach in pediatric overweight interventions. Results provide evidence that overweight African American girls face significant weight stigmatization and suggest areas to target regarding intervention implementation. KEY WORDS: pediatric overweight; African American; adolescent girls; intervention; teasing.
The percentage of children and adolescents who are overweight or at risk for obesity has more than doubled in the last three decades (Flegal, Carroll, Ogden, & Johnson, 2002; Kimm et al., 2002). According to the latest data from the National Health and Nutrition Examination Survey (NHANES, Hedley et al., 2004) in 1999–2002, 29.9% of children
aged 6–19 were at risk for overweight (i.e., had a body mass index or BMI for age ≥ 85th percentile), or were overweight (BMI for age ≥ 95th percentile). Pediatric overweight is associated with numerous health risks, such as hypertension, Type 2 diabetes, asthma, and musculoskeletal problems (CDC, 2003; Gennuso, Epstein, Paluch, & Cerny, 1998; Kiess et al., 2001; Sorof & Daniels, 2002). Moreover, compared to their normal-weight peers, overweight children and adolescents have significantly poorer quality of life (QOL, Schwimmer, Burwinkle, & Varni, 2003). Indeed, Schwimmer et al. (2003) found that severely overweight children’s QOL was similar to that of children undergoing chemotherapy. Longitudinal research has found that overweight in adolescents is associated with low self-esteem, behavioral problems, loneliness, and risky health behaviors, including tobacco and alcohol use (Strauss, 2000; Young-Hyman, Schlundt, Herman-Wenderoth, & Bozylinski, 2003).
1
An earlier version of this paper was presented to the meetings of the American Psychological Association, Honolulu, HI, July 30, 2004. 2 Department of Psychology, Virginia Commonwealth University, Richmond, Virginia. 3 Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia. 4 Department of Pediatrics and the Hayes Willis Health Center, Virginia Commonwealth University, Richmond, Virginia. 5 Correspondence should be addressed to Marilyn Stern, Departments of Psychology and Pediatrics, Virginia Commonwealth University, 808 W. Franklin St., Richmond, Virginia 23284; e-mail:
[email protected].
217 C 2006 Springer Science+Business Media, Inc. 1068-9583/06/0900-0217/0
218 Moreover, overweight children are at significant risk for obesity in adulthood (Serdula et al., 1993).
African American Girls: A Group at Particular Risk Although rates of pediatric overweight have increased in both genders and in all ethnic groups, females and children of color are at greater risk than Caucasians (e.g., Baskin, Ahluwalia, & Resnicow, 2001; Melnyk & Weinstein, 1994; Ogden, Flegal, Carroll, & Johnson, 2002). In particular, overweight has increased at a faster pace in African American girls than in Caucasian girls (Baskin et al., 2001; Jelalian & Mehlenbeck, 2003). African American girls age 6–19 are significantly more likely to be overweight than their Caucasian peers (23.6% vs. 12.7%, Hedley et al., 2004). These ethnic disparities appear to persist into adulthood. Approximately 47% of African American adult women age 20–39 are obese (i.e., BMI ≥ 30). In contrast, 25% of Caucasian women in the same age group have BMIs ≥ 30 (Hedley et al., 2004). Furthermore, rates of several obesity-related health problems such as diabetes and hypertension are significantly higher in African American women compared to Caucasian women (Melnyk & Weinstein, 1994; Paeratakul, Lovejoy, Ryan, & Bray, 2002). Consequently, many authors have argued that obesity intervention for African American girls should begin before they reach adulthood (e.g., Institute of Medicine, 2005; Melnyk & Weinstein, 1994). Indeed, a recent Institute of Medicine (IOM, 2005) report emphasized the urgent need to initiate childhood obesity interventions, particularly within diverse ethnic groups. Moreover, the IOM report noted the need for culturally appropriate and targeted interventions. Although the IOM report was published subsequent to the initiation of the present study, our efforts were consistent with its objectives as we attempted to develop an intervention for overweight African American adolescent girls at risk for adult obesity. We began our efforts by conducting focus groups with African American adolescent girls and their mothers. These groups addressed thoughts and beliefs about weight, exercise and healthy eating. We felt that it was extremely important to include parents from the beginning, as previous research suggests that pediatric obesity interventions are more successful when parents are involved (Levine, Ringham, Kalarchian, Wisniewski, & Marcus, 2001; Wadden et al., 1990; Wrotniak, Epstein, Paluch,
Stern, Mazzeo, Porter, Gerke, Bryan, and Laver & Roemmich, 2004). Thus, our first aim was to generate ideas that would facilitate the development of a culturally appropriate intervention targeted at overweight African American adolescent girls. In the second part of this paper, we present baseline data from the intervention which was informed by the focus groups. Both the focus group and baseline data provide insight into correlates of healthy eating and exercise behaviors among African American girls and their mothers.
STUDY 1: FOCUS GROUPS Focus group methodology was used to address the first aim, exploring weight and related concerns of African American girls and their mothers. A focus group is a qualitative method that is particularly useful when relatively little empirical data are available about a research topic, as they facilitate exploration and hypothesis generation (Elliott & Shewchuk, 2002). The goal was to identify participants’ concerns and explore possible intervention activities. Special attention was given to the influence of ethnicity and gender on eating and weight-related behaviors.
METHOD
Participants A total of 10 African American adolescent females (all of whom were overweight or at risk for overweight with BMIs of at least the 85th percentile for age, M age = 14 years) and their mothers participated in focus groups (Elliott & Shewchuk, 2002). Adolescents identified as being at the 85th percentile for weight (4/10 girls) or above (6/10 girls) by their primary physicians were referred to the groups. Nearly all (8/10) of the families participating were from low or working class (2/10) socio-economic status (SES) backgrounds. For this study, SES was estimated using parental educational and occupational backgrounds.
Procedure Notices about the groups were circulated to local medical clinics with a high representation of African American patients. Following suggestions from
Correlates of Overweight: African American Adolescent Girls previous research (Levine et al., 2001), both mothers and daughters were invited to participate. Groups met in a conference room of a medical clinic and were conducted separately for adolescents and their mothers. Two African American female doctoral students in Counseling Psychology with prior experience in conducting focus groups served as facilitators. Groups were audiotaped for subsequent content coding. Specific open-ended questions were used to structure the group discussions (Elliott & Shewchuk, 2002). Question topics explored both mothers’ and adolescents’ perceptions of: 1) the causes of overweight, 2) their willingness to participate in an intervention program (and what would enhance their motivation), 3) perceived barriers to participation, 4) the importance and meaning of healthy eating and exercise, and 5) their perceptions about ideal body size. Additionally, mothers and daughters completed questionnaires assessing their perceptions of eating and exercise behaviors and self-esteem. Institutional review board approval for all aspects of the study was obtained prior to its initiation. All participants signed consent or assent forms and were offered a gift certificate of $15 (for each mother and daughter) to a major retail chain for their participation.
Measures Perceptions of eating, exercise, and body size (PEEB). This 18-item survey was designed for this series of studies. The adolescent version included questions about eating, exercise behaviors (e.g., “I enjoy exercising”), and weight (e.g., “Do you think your weight is a health problem”). Adolescents also answered questions regarding their beliefs about weight, its relationship to health, and the causes of overweight (e.g., “If you eat enough healthy foods, it doesn’t matter how much you weigh”). Most items were rated on a 5-point scale, ranging from “strongly agree” to “strongly disagree.” Mothers responded to the same questions by indicating how they believed their daughters felt about each of the items. Mothers also were asked additional questions to determine how they felt about themselves (e.g., “about their own body satisfaction”); what they understood about the relationship between weight and health (e.g., “height and weight charts don’t tell me much about my child’s health”), and their family history of weight-related medical problems.
219 Content analyses of audiotapes. Two research assistants independently transcribed and reviewed all of the audiotapes. Transcriptions were then checked for accuracy by another assistant. Two additional assistants then reviewed the transcripts and were instructed to identify common themes across all the transcripts. Senior members of the research team then reviewed the list of identified themes as well as the responses mothers and daughters gave to each of the structured questions asked during the focus groups to derive patterns of responses.
RESULTS Most of the mothers reported that an immediate family member had diabetes (80%), high blood pressure (100%), or high cholesterol (70%), suggesting that participants had a family history of health concerns that could be related to overweight or obesity. As can be seen in Table I, both adolescents and their mothers believed that their weight (or their daughter’s) was a health problem, were worried about their weight (or their daughter’s), and believed that they (or their daughter) were heavier than they should be. In addition, 70% of mothers considered their own weight to be a health problem. Although the majority of both adolescents (70%) and mothers (80%) felt as if they (or their daughter) were too heavy, at least one adolescent reported that she was “too skinny” and another described herself as “just right.” Indeed, one-half of the adolescents described themselves as having a “medium” body type and one even described herself as “small.” These findings are noteworthy; as all participants were at least 85th percentile for weight (BMI) and most (6/10) could be described as overweight for age (over 95th percentile). Thus, there appears to be some range in the description and/or perceptions of body size. Responses to the PEEB also revealed several interesting discrepancies between adolescents’ and mothers’ perceptions and experiences. For example, as indicated in Table I, adolescents and mothers differed significantly in whether or not they were currently trying to lose weight. All the adolescents indicated that they were currently trying to lose weight, compared to 60% of mothers. Adolescents were less likely than their mothers to believe that if members of their family were overweight, then they would be overweight. Daughters also were less likely than their mothers to believe that weight problems were caused by genes. However, adolescents were more
220
Stern, Mazzeo, Porter, Gerke, Bryan, and Laver Table I. Responses of Mothers and Daughters to Overlapping Items of the PEEBa Item View weight as a health problem Worried about weight Heavier than they should be Currently trying to lose weight If family members were overweight, then they would be overweight Weight problems caused by genes If active, weight not important Perceptions of confidence
% of Mothers
% of Daughters
t
70%; M = 3.7 (1.4) 90%; M = 4.3 (.68) 80%; M = 4.3 (.82) 60%; (Yes) 30%; M = 3.1 (1.3)
70%; M = 3.9 (.99) 70%; M = 3.4 (1.6) 70%; M = 3.9 (.99) 100%; (Yes) 10%; M = 2.0 (1.4)
1.10 1.64 .38 2.12∗∗ 2.30∗∗
90%; M = 3.0 (.47) 10%; M = 2.2 (1.2) 30%; M = 3.2 (.92)
50%; M = 2.3 (1.3) 50%; M = 3.2 (1.1) 60%; M = 4.2 (.97)
1.28 2.20∗∗ 3.19∗∗
a For each of the items, except for item asking whether the respondent was trying to lose weight now, mothers responded on the basis of how they viewed their daughters whereas daughters responded on how they viewed themselves. Percentages and Means (based on a scale from 1 to 5, with the exception of ‘yes’ vs. ‘no’ items asking whether the respondent was trying to lose weight) reflect affirmative endorsement of the item. Standard deviations are indicated within parenthesis. On the one exception, both mothers and daughters responded about their own behavior. ∗∗ t-test comparisons all p < .05.
likely than their mothers to believe that if they stayed active, their weight was not very important. When asked if they felt confident in themselves, daughters rated their self-confidence relatively high, whereas mothers perceived their daughters’ self-confidence to be significantly lower. Content analysis of the audiotapes revealed several themes consistent with some of these issues. Mothers frequently described their daughters as “solid” or “big-boned, ” and did not use terms specific to weight such as “weight problem” or “overweight.” This is also consistent with the research of Baugham and colleagues (Baugham, Chamberlin, Deeks, Powers, & Whitaker, 2000), which found that most mothers of overweight children (79%) did not view their children as overweight, although they were generally accurate in assessing their own weight status. Mothers in the current study believed that their daughters were fairly secure with their body size. Mothers also were concerned that they would appear hypocritical if they encouraged their daughters to eat healthy foods and lose weight when they themselves were overweight. However, mothers were unsure what was meant by healthy foods and reported that cooking “healthy meals” and exercising were unappealing. When asked about their willingness to have their daughter participate in the intervention, mothers noted that they would be enthusiastic about it if it were convenient, child care was available, and it was not too expensive. Daughters frequently mentioned the teasing they experienced because of their size. When asked about participating in a multidisciplinary clinic aimed at promoting healthy eating and exercise, daughters
were generally enthused (especially if the program was fun and the instructors were kind), but were unsure if their mothers would participate.
DISCUSSION AND IMPLICATIONS This study provides some interesting information about pediatric overweight and its correlates in African American girls, a group at high-risk for this condition. In particular, the focus group results suggest that, although mothers and their daughters shared some similar views about weight and health issues, there were also some important discrepancies between mothers’ and adolescent girls’ perceptions regarding weight and exercise. For example, compared to daughters, mothers were more likely to believe that eating healthier and exercising were unappealing behaviors that would not necessarily resolve their child’s (or their own) weight problems. Perhaps these beliefs were associated with mothers’ tendency to view weight problems as caused by genetic factors. It is thus not surprising that mothers were less likely than their daughters to report currently trying to lose weight. These findings actually underscore the importance of involving the entire family when designing a pediatric obesity intervention, to ensure that all believe in the efficacy and importance of the intervention, and are supportive of the identified patient. Further, our results are similar to those of Jain and colleagues (Jain et al., 2001), who conducted focus groups with low-income mothers (72.2% of whom were African American). Specifically, these
Correlates of Overweight: African American Adolescent Girls authors found that mothers were likely to view genetic factors as the primary determinant of children’s weight status, and as a result, believed that changes in the environment (e.g., alterations in eating and exercise behaviors) would have little impact on body shape. Moreover, Jain et al. also found that mothers used terms such as “solid” or “big-boned” to describe their children, and did not generally consider them overweight unless their weight interfered with their activity level or if they were teased about their size. Daughters’ responses are also consistent with previous investigations conducted with African American adolescents. Neumark-Sztainer and colleagues found that overweight African American girls experience stigmatization (including teasing) due to their weight at rates similar to their Caucasian peers (Neumark-Sztainer, Story, & Faibisch, 1998). Further, Young-Hyman and colleagues (YoungHyman et al., 2003) found that weight was inversely associated with appearance-related self-esteem in overweight African American boys and girls ages 8–10. In addition, girls in their sample had significantly lower appearance-related self-esteem than boys, although there were no gender differences in BMI. Finally, children who reported weight-related teasing had lower global and appearance-related self-esteem. A final issue of note is that there appear to be some inconsistencies in the girls’ descriptions of their weight. For example, although all of them reported currently trying to lose weight, nearly onethird of the sample indicated that they did not think they were too heavy, or that their weight was a health problem. In fact, one even described herself as “too skinny.” This is noteworthy, as all of these girls had been referred by their physicians because of their weight status. Moreover, research with African American adults has led some researchers to suggest that there may be a curvilinear association between body image dissatisfaction and health eating and exercise behavior (Heinberg, Thompson, & Matzon, 2001). Thus, it is unclear whether these girls’ weight concern is sufficient to motivate them to pursue the challenges involved in changing their eating and exercise habits. Further exploration of these inconsistencies in self-perceptions and behavior would be worthwhile, particularly if denial is being used as a coping strategy among these adolescents. However, speculating on this possibility goes beyond the scope of our present paper. Moreover, several limitations of the focus groups should be noted. In particular, their generalizability is limited due to the small sam-
221 ple size and homogenous socio-economic and educational backgrounds of the participants. Despite these limitations, we used the information gathered from these focus groups to inform our intervention. Specifically, we emphasized a family framework, provided no-cost treatment, were sensitive to cultural factors, and used a multidisciplinary approach. For example, because our participants defined overweight differently from what the majority culture and the media often emphasize and because they seemed to hold varying views of what was meant by an ideal body size, adjustments were made to our primary goals for the intervention. The multidisciplinary team members all agreed to make the attainment of a healthier life style as the primary program goal rather than focusing specifically on weight loss as the goal. We felt that this broader goal was more consistent with the information we gathered from conducting our focus groups.
STUDY 2: BASELINE INTERVENTION DATA A multidisciplinary team consisting of medical personnel, psychologists, exercise physiologists, rehabilitation specialists and dieticians was established to address the problems and challenges of pediatric obesity in a culturally diverse population beginning in late November 2003. Children and adolescents (11–17 years) were eligible only if they were ≥95th for BMI and at least one of their primary caretakers was committed to being involved in all aspects of the intervention. Each child was also required to have a primary care physician, who was contacted regularly regarding the child’s progress and was responsible for all of his or her other medical needs. The baseline phase of this intervention is described in the following section.
Participants Thirty-nine female African American adolescents between the ages of 11 and 17 (M age = 13.96 years) and their mothers completed the baseline assessment. The mean BMI (for age, gender, and height) for all participating adolescents were in the at-risk for overweight for age range (M BMI = 40.8; Median BMI = 38.3, range 27.3 to 74.1; M weight = 108.3 kg, range 60.2 kg to 210.90 kg.); 100% had BMIs ≥ 95th percentile. Although the program was offered at no cost, insurance status was
222 obtained as a proxy for socio-economic status (SES) background. Over one-half (58%) of the sample had some form of private insurance while 42% were on Medicaid. The relatively high proportion of families who were not insured is consistent with the lower SES population generally seen at this urban-based medical center. Insurance status was, however, not significantly related to BMI or weight, t(38) = 1.57, p = 13. When mothers were asked about familial medical history, 69% reported family histories of diabetes, 53% high blood pressure, 26% heart disease, and 38% high cholesterol. Thus, these families appear to have relatively high rates of diseases commonly associated with obesity and overweight. Procedure The overall program consisted of three phases (Initial 6 month phase, Maintenance phase of 6 months, and Phase III of 12 months), and focused on 3 major components: nutrition, exercise, and behavior modification.6 The goals of the program were individualized for each patient, were negotiated between the healthcare provider, parent and child, and were regularly monitored by a personal notebook in which goals were specified and then reviewed by each of the program health care providers during followup sessions. As noted above and based on our initial work with the focus groups, goals of the program emphasized working towards a healthier lifestyle (i.e., eating a more balanced and healthy diet and exercising regularly) and not necessarily on specific weight loss targets. Every member of the team was committed to this lifestyle change approach, and this orientation was communicated to adolescents and their parents. The measures described here were completed as part of the baseline assessment. Prior to any data collection, a detailed consent process was conducted with each child and adult to explain study requirements. This consent process had been fully approved by our university’s Institutional Review Board. During the consent process, adolescents and their mothers (or primary caregivers) were told that they can choose to complete any or all of the measures. Although data collection was somewhat lengthy, it was generally embedded within a full day
6
A detailed description of the multidisciplinary intervention program and all its components is beyond the scope of the present study and can be obtained by writing to the first author.
Stern, Mazzeo, Porter, Gerke, Bryan, and Laver in which families participate in a number of laboratory tests, medical exams and fitness tests as part of the baseline evaluation necessary for adolescents to be entered into the intervention program. Families completed the psychosocial measures while waiting to meet with the various healthcare professionals, thereby streamlining the assessment and intake process. Measures Both mothers and daughters completed each of the following measures, with exceptions noted. Perceptions of Eating, Exercise, and Body size (PEEB). This questionnaire was described above and used in the focus groups. Coopersmith Self-esteem Inventory (SEI; Coopersmith, 1981). The SEI assesses global self-esteem and includes 25 declarative, self-descriptive items worded in the first person. Respondents indicate whether the item is “like me” or “unlike me.” One point is assigned for each item connoting high selfesteem. For the purposes of the present study, mothers were asked to respond to each item as they believed their child would. Mean Cronbach’s alpha for the 25-item version of the SEI is .83; test-retest reliability is good (Blascovich & Tomaka, 1991). The SEI has been used with African American adolescents (e.g., Chapman & Mullis, 2000). Family Environment Scale (FES; Moos & Moos, 1986). The three subscales which comprise the relationship dimension of the FES scale were administered to both mothers and adolescents. These 27 true-false items assess family cohesion, family expressiveness and family conflict, and have been found to yield internally consistent and stable scores (Moos & Moos, 1986). Internal consistency reliability estimates for the three FES subscales were .71 for Expressiveness, .75 for Conflict, and.78 for Cohesion. Previous studies have used the FES with African American adolescents (e.g., Clark & Armstead, 2000). Pediatric Health-Related Quality of Life (PedsQL4.0). The PedsQL uses a modular approach to health-related quality of life (HRQOL) measurement (Varni, Seid, & Kurtin, 2001; Varni, Seid, & Rode, 1999), and has been widely used with adolescents with chronic illnesses. The 23-item measure assesses adolescents’ perceptions of how their health affects their daily life in four areas: physical, emotional (distress and depression), social, and school. Reliability is estimated at .83 for adolescent patients.
Correlates of Overweight: African American Adolescent Girls The PedsQL is deemed to be more age appropriate for adolescents than the Rand-36 often used in health research (Varni et al., 2001). Mothers completed the measure by indicating their perceptions of their adolescent. The Vulnerable Child Scale (VCS; Perrin, West, & Culley, 1989). This scale consists of 16 items rated on a 4-point scale. The statements express various concerns about a child’s health or well-being and assess perceptions of vulnerability to illness (Stern, Karraker, McIntosh, Moritzen, & Olexa, in press). The VCS yields internally consistent (Cronbach’s ( = .75) and stable (test-retest r = .95) scores. For the purposes of this study, we adapted the VCS for selfreport by adolescents. Life Orientation Test-Revised (LOT-R; Scheier, Carver, & Bridges, 1994). Only adolescents completed this 10-item scale assessing dispositional optimism, or global expectations that good things will be plentiful and bad things will be scarce in the future. The LOT-R includes 6 scored items (plus four filler items). Three of the scored items are positively valenced and three are negatively valenced. The six scored items are added to achieve a dispositional optimism total. Cronbach’s alpha coefficients for the LOT-R have been reported at .72 with average testretest reliability coefficients of .79 (Scheier & Carver, 1992; Schulz et al., 1996). Perceptions of Teasing Scale (POTS; Thompson, Cattarin, Fowler, & Fisher, 1995). Adolescents completed this 11-item scale assessing perceptions of teasing. The POTS has two subscales, general weight teasing and competency teasing, and yields reliable and valid scores. The alpha for general weight is .94 and for competency is .78. Child Feeding Questionnaire. The Child Feeding Questionnaire (CFQ; Birch et al., 2001) is a 31item self-report measure which assesses the beliefs, attitudes and behaviors of parents regarding child feeding. The CFQ was administered to mothers in the study. This measure has been found to yield internally consistent scores (alphas range from .70 to .86). It also manifested factorial validity in samples of Caucasian and Hispanic parents (Birch et al., 2001) and has previously been used with African Americans (Anderson, Hughes, Fisher, & Nicklas, 2005). CFQ items fall into two broad categories: risk factors and concerns (four factors summed to assess parental control in child feeding; alpha in current study = .98) and control in child feeding – attitudes and practices (three factors summed to assess dimensions of control in child feeding; alpha in current study = .97).
223 RESULTS Data analyses proceeded in the following order. First, relationships among eating and exercise behaviors (PEEB), self-esteem (SEI), optimism (LOT-R), and teasing (POTS) were examined via correlations. Second, the relative contributions of self-esteem, optimism, perceived vulnerability, and family environment to adolescent QOL as well as maternal feeding style were examined in a series of regressions. Finally, we examined differences between mothers’ and daughters’ responses to the questionnaires. Associations between adolescents’ perceptions of weight-related issues and psychosocial adjustment. As can be seen in Table II, correlations between items on the PEEB and the SEI generally indicated that adolescents with higher self-esteem viewed their appearance more positively and were less likely to engage in positive health habits. For example, adolescents with higher self-esteem were less likely to think they would look better if they lost weight, less likely to exercise regularly and less likely to believe that their weight was a health problem. Similarly, adolescents who were more optimistic also reported greater self-confidence, and were more satisfied with their appearance. In contrast, weight and appearance related teasing was associated with less self-confidence, and with feeling worried about one’s weight. Girls experiencing greater teasing were also more likely to report that they were currently trying to lose weight and exercising. In addition, girls teased at higher levels were more likely to consider their weight a health problem, to be concerned about being overweight in the future, and to be interested in a weight loss program. Interestingly, girls reporting greater teasing were also more likely to acknowledge that they “ate too much.” Of note, the association between BMI percentile and teasing was non-significant (r = .12, p = .30). Thus, the relationship found among teasing and health behaviors does not seem to be related to degree of overweight for age. Associations between adolescent perceptions and QOL. A series of multiple regressions (four) were conducted to investigate which variables were most strongly associated with adolescent QOL. Specifically, perceived vulnerability, teasing, selfesteem, optimism and family conflict were entered as independent variables, and each of the four QOL subscales was treated separately as the dependent variable. For social QOL, teasing emerged as the only independent variable significantly related to this
224
Stern, Mazzeo, Porter, Gerke, Bryan, and Laver Table II. Inter-Correlations: Adolescents’ Perceptions of Eating. Exercise, and Body Size With Psychosocial Adjustment Perceptions
Would look better if lost weight Likely to exercise Worried would become overweight in the future Could prevent self from becoming overweight Believed genes caused weight problems Family believes they should lose weight Trying to lose weight Worried about current weight Believe they ate too much Believe weight is a health problem Believe were overweight Confident in self How feel about the way they look Interested in weight loss program
Self-esteem
Teasing
−.54∗∗∗ −.28∗ −.46∗∗ −.32∗ −.12 −.43∗∗∗ −.19 −.40∗∗ −.27 −.52∗∗∗ −.32† .20 .48∗∗ −.20
.14 .37∗ .31∗ .47∗∗ .10 .10 .39∗ .52∗∗ .48∗∗ .31∗ .33∗ −.42∗ −.26† .50∗∗
Optimism −.18 .09 −.09 −.33∗ .15 −.06 .03 −.08 −.15 −.18 −.23 .36∗ .45∗∗ −.12
Note. For each of the items, higher scores reflect positive endorsement of item (on scale from 1 to 5). ∗ p < .05; ∗∗ p < .01; ∗∗∗ p < .001; † p < .07.
dimension of QOL, R2 = .64, F(5,24) = 6.64, p = .001; higher levels of teasing were associated with poorer social QOL, β = .55, t = 3.01, p = .007. In contrast, emotional QOL was most strongly associated with perceptions of lowered vulnerability, β = .52, t = 2.69, p = .01, and higher self-esteem, β = .43, t = 2.08, p = .05, (overall R2 = .55, F(5,24) = 4.64, p = 006). For school QOL, although the overall test was significant, R2 = .49, F(5,24) = 3.69, p = .017, only two predictors emerged as marginally significant. Greater perceptions of vulnerability, β = .40, t = 1.91, p = .07, and greater perceptions of family conflict, β = .33, t = 1.90, p = .07, were associated with lower school QOL. Physical QOL was not found to be significantly associated with any of the independent variables included in this study. Factors associated with maternal feeding style. Multiple regressions in which perceived vulnerability, self-esteem, and family conflict were treated as independent variables were conducted on each of the two CFQ factors: risk and concerns, R2 = .41, F(3,24) = 4.90, p = .01, and control of feeding, R2 = .31, F(3,26) = 3.51, p = .03. Mothers’ perceptions of adolescent self-esteem, β = .46, t = 2.37, p = .028, and family conflict, β = .40, t = 2.07, p = .05, accounted for significant variance in the CFQ risk and concerns factor. Similarly, mothers’ perceptions of adolescent self-esteem, β = .43, t = 2.10, p = .047, were significantly associated with maternal control of feeding. Overall, mothers who view their daughters as higher in self-esteem appear to be less restrictive of their daughters’ eating, exert less pressure concerning their daughters’ dietary choices, show less concern about their daughters’ weight, and are less
likely to monitor their daughters’ eating. In addition, mothers with higher scores on the CFQ risks and concerns subscale reported that they believed their adolescents had poorer physical, r(25) = .36, p = .047, and emotional QOL, r(25) = .37, p = .03. Similarly, mothers who reported maintaining greater control over their adolescents’ feeding behaviors perceived their adolescents as having poorer physical r(25) = .34, p = .049, and emotional QOL, r(25) = .39, p = .019. Differences in mothers’ and daughters’ perceptions. Next we conducted a series of multivariate analyses of variance (MANOVAs) to assess differences in mothers’ and daughters’ responses to the various measures. Overall, mothers rated their daughters’ QOL significantly lower than the adolescents rated themselves, F(4,46) = 3.85, p = .009. Specifically, significant differences were found on the physical F(1,49) = 11.68, p = .001 (M Mothers = 12.60, S = 6.9 vs. M Adolescents = 7.19, S = 3.99), and social domains, F(1,49) = 4.27, p = .04 (M Mothers = 7.80, S = 5.3, vs. M Adolescents = 5.07, S = 3.8), with higher scores reflecting poorer functioning on that domain. In addition, a MANOVA indicated that mothers’ and daughters’ FES responses differed significantly, F(3,47) = 4.51, p = .007, with follow-up tests suggesting that adolescents perceived less family expressiveness F(1,49) = 4.38, p = .037, and greater family conflict than mothers F(1,49) = 6.24, p = .016. Mothers and daughters did not significantly differ in perceived vulnerability (VCS) and similar to the focus group findings, no differences were found in perceptions of adolescent self-esteem.
Correlates of Overweight: African American Adolescent Girls As was also the case in the focus group portion of the study, mothers and adolescents differed significantly on a number of baseline questionnaire items assessing eating and exercise behaviors, as well as perceptions of body size (PEEB). Mothers (M = 4.45, on a 5-point scale, S = .89) worried more than adolescents (M = 3.7, S = 1.3) that the adolescent would be overweight in the future, F(1,61) = 7.45, p = .008. Adolescents reported that they currently exercised significantly more (M = 3.2 times per wk, S = 1.02) than their mothers said they did (M = 1.55 times per wk, S = .67), F(1,61) = 53.73, p = .001. Adolescents reported that they worried more about their current weight than their mothers thought they did, F(1,61) = 6.47, p = .01. Adolescents reported that they were more confident in their ability to follow through with the weight management program than mothers believed, F(1,61) = 8.29, p = .005. However, mothers and adolescents did not differ in their interest in joining the multidisciplinary program, their perceptions of their body type, how much they enjoyed exercising, and whether they believed they could do something to prevent becoming overweight (all p > .05).
GENERAL DISCUSSION Recent media attention to the growing epidemic of childhood overweight has brought the issue of obesity as a chronic and serious illness to the forefront. Yet, despite this increased attention, the problems associated with obesity remain complex. There is a relative dearth of research on effective treatments for obesity, and a need to develop treatments that are effective and appropriate for specific age, gender, and cultural groups (Flodmark, Lissau, Moreno, Pietrobelli, & Widhalm, 2004; IOM, 2005). Moreover, although pediatric obesity interventions are generally more successful than comparable treatments targeted at adults, weight loss among children enrolled in these programs is often suboptimal (e.g., see Kirk, Scott, & Daniels, 2005 for a review). Thus, there remains a need to clarify factors related to the maintenance of unhealthy eating and exercise behaviors, as well as those associated with motivation to pursue obesity treatment. Because increases in rates of pediatric overweight have been particularly dramatic among female African Americans, the current research focused on identifying psychosocial factors that might be contributing to this ethnic health disparity among
225 adolescents. Results revealed several paradoxes that might ultimately add to our understanding of the complex issues involved in obesity and its treatment. Consistent with previous research (e.g., Sherry et al., 2004), African American mothers were generally found to view their daughters’ weight problems as less serious than would be expected of adolescents who objectively are severely overweight and at risk for adult obesity. Moreover, mothers who viewed their daughters as having higher self-esteem seemed especially likely to minimize the health problems associated with obesity, as indicated by the finding that they were less restrictive of their daughters’ eating behaviors, and more likely to allow their daughters to make their own decisions about what to eat on a daily basis. In contrast, mothers who perceived their daughters as lower in self-esteem and QOL were more likely to impose restrictions on their daughters’ eating and show greater concern about their food choices. The observed relationship between self-esteem and willingness to engage in positive health behaviors was also somewhat counterintuitive. Girls who reported lower self-esteem expressed a greater willingness to work towards increasing their healthy behaviors, including exercising more and eating less. In addition, girls who reported experiencing weightrelated teasing also were more likely to acknowledge that their weight was a health problem, that they were worried about their weight, and that they were interested in the intervention. It is noteworthy that the level of perceived teasing found in the current study is consistent with findings of previous research with diverse adolescent girls (NeumarkSztainer et al., 1998). These results suggest that despite the fact that African American girls endorse a heavier body ideal than their Caucasian peers (e.g., Parnell et al., 1996), this “size acceptance” does not appear to extend to the very overweight. According to our results, these girls do experience significant teasing that adversely affects their well-being. Another somewhat unexpected finding was that overweight adolescents with higher levels of selfesteem and self-confidence were more satisfied with their bodies, felt better about themselves (or at least reported that they felt more positive about themselves), and did not generally perceive themselves as being teased. Further, a substantial proportion of adolescents in both Study 1 and Study 2 did not identify themselves as being severely overweight. This pattern of results is consistent with that found in a previous study conducted
226 with African American obese adult older women (Heinberg, Haythornthwaite, Rosofsky, McCarron, & Clarke, 2000). Specifically, Heinberg and colleagues (Heinberg et al., 2000) found no BMI differences between objectively obese women who described themselves as “very overweight” and those who described themselves as “very underweight.” Moreover, in the same study, these authors found that individuals who were more dissatisfied with their appearance at baseline lost more weight in a 15-month long obesity intervention. As noted previously, this suggests that there may be a curvilinear association between body image dissatisfaction and health eating and exercise behavior (Heinberg et al., 2001). This association is similar to that found between distress and other types of health behavior, such as cancer screening (e.g., Hailey, 1991). Clinical implications of the finding that body satisfaction is associated with less motivation for weight loss among obese individuals are complicated. Clearly, given the association between high levels of body dissatisfaction and eating disorders (e.g., Stice & Shaw, 2002), practitioners should not be encouraged to increase patients’ body image distress. However, perhaps obese individuals with low body image dissatisfaction could benefit from increased emphasis on the non-appearance related benefits of weight loss, such as the health consequences of behavioral change (Heinberg et al., 2001). In addition, techniques such as motivational interviewing could be incorporated into pediatric obesity interventions to enhance outcomes (Kirk et al., 2005). We are currently including this approach in our behavioral intervention. The current results also highlight the need for clinical psychologists working in medical settings to use a family based approach. Parents must be engaged in the intervention process so that they increase their understanding of the factors involved in changing health habits and facilitating positive life style change in their daughters. This can be extremely challenging; a recent national survey of pediatricians, pediatric nurse practitioners, and registered dieticians (Story et al., 2002), found that lack of parent involvement was one of the most frequently cited barriers to the treatment of overweight children and adolescents. However, such efforts seem to be highly fruitful, even among severely overweight children. For example, Levine and colleagues (Levine et al., 2001) found that a family-based obesity intervention targeted at children who were ≥160% of their ideal body weight
Stern, Mazzeo, Porter, Gerke, Bryan, and Laver was associated with both significant weight loss, and improvements in psychosocial functioning. Although the current findings are intriguing and suggest several areas to focus on in future studies, caution needs to be used in drawing conclusions based on these results. These studies are limited by the relatively small sample size and cross-sectional design. Clearly, further research which examines the same factors addressed here and uses a larger sample, examines adolescents over time, and specifically considers outcomes of treatment are necessary. Despite its limitations, however, the results reported here are at least suggestive of areas to target for further exploration. Consistent with the IOM report on the importance of considering cultural and contextual factors related to pediatric overweight, psychologists working within medical settings also need to assess barriers that could prevent families from fully participating in interventions. We have, for example, implemented some changes in our intervention program in an attempt to increase families’ motivation to participate and maintain adherence with the program. For example, we have begun to partner with community outlets, such as the local YMCAs, and have continued to come up with strategies to reduce the cost of the program so that we could continue to offer it at no cost to our participants. For example, we use a treatment model in which a licensed psychologist provides supervision to doctoral students in training. This minimizes the cost of the behavioral component of the intervention, and seems to be working well from a practical perspective. Whether these strategies are effective and have an effect on behavioral outcomes has not yet been evaluated. However, we believe that developing programs in which parents can participate while their adolescents are attending the various intervention activities also enhances the entire family’s motivation and compliance. We are currently working to broaden our intervention program and strengthen all of these elements. Moreover, our experience has also shown us that it is important to continuously reevaluate the intervention and determine how it can be changed to more effectively meet its goals.
ACKNOWLEDGMENTS Preparation of this paper is partially supported by a VA Premier contract to the Dept. of Pediatrics, Virginia Commonwealth University, and by NIH
Correlates of Overweight: African American Adolescent Girls Grant MH-068520 to Dr. Mazzeo. We are grateful to all the mothers and daughters who agreed to participate in this project and for the many colleagues who have and continue to work on the T.E.E.N.S. Healthy Weight Management Program. Among those we need to extend our thanks to are Janet Delorme, Meghan Creehan, Melanie Bean, LaShanda Jones, and Dr. Ronald Evans and his students.
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