Journal of Adolescent Health
Volume 38, Issue 5 , Pages 569-574, May 2006

Psychosocial and behavioral correlates of dieting among overweight and non-overweight adolescents

  • Scott Crow, M.D.

      Affiliations

    • Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota
    • Corresponding Author InformationAddress correspondence to: Scott Crow, M.D., Department of Psychiatry, University of Minnesota Medical School, F292/2A West Building, 2450 Riverside Avenue, Minneapolis, MN 55454-1495
    • ,
  • Marla E. Eisenberg, Sc.D., M.P.H.

      Affiliations

    • Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
    • ,
  • Mary Story, Ph.D.

      Affiliations

    • School of Public Health, University of Minnesota, Minneapolis, Minnesota
    • ,
  • Dianne Neumark-Sztainer, Ph.D.

      Affiliations

    • Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota

Received 5 January 2005; accepted 6 May 2005.

Article Outline

Abstract 

Purpose

To examine correlates of dieting behavior in overweight and non-overweight youth.

Methods

Data came from Project EAT (Eating Among Teens), a study of eating and weight-related attitudes, behaviors, and psychosocial variables among 4746 adolescents in public schools. Logistic regression was used to compare dieters and non-dieters, and to examine interactions of dieting and overweight status.

Results

Approximately one third (31.8%) of the sample was overweight. Dieting in the previous year was reported by 55.2% of girls and 25.9% of boys. Dieting was associated with similarly elevated rates of extreme weight control behaviors, body dissatisfaction, and depression in both the non-overweight and overweight groups for both boys and girls. Girls reporting dieting behavior in both the non-overweight and overweight groups had similarly elevated risk for cigarette use, alcohol use, and marijuana use.

Conclusions

The negative correlates of dieting are similarly common among teens of varying weight status. These data suggest that dieting may not be a preferred method of weight management, even for overweight adolescents. Regardless of weight status, dieting may be a marker for other unhealthy behaviors and depressed mood in adolescents.

Keywords:  Dieting , Adolescents , Overweight , Body dissatisfaction , Depression

 

Overweight and obesity are highly prevalent in many parts of the world, including the United States [1], [2]. This prevalence has risen at a rapid rate among both youth and adults [3], [4]. Obesity has received increasing attention of late, triggering increased interest in both the treatment and prevention of obesity among children and adolescents. For both prevention efforts and for treatment, weight loss dieting may be recommended [5].

Dieting is a widely prevalent behavior among adolescents in many countries, but is associated with a wide range of problematic attitudes and behaviors [6], [7], [8], [9], [10], [11], [12]. The use of extreme or unhealthy weight control behaviors is associated with other health risk behaviors [13], [14]; the same may be true for typical weight loss dieting [15], [16], [17], [18], [19], [20], [21]. Overweight adolescents engage in dieting more often than do non-overweight adolescents [22], [23], [24], [25]; at the same time, dieting also predicts weight gain and obesity onset in longitudinal studies [26], [27].

Thus, dieting behavior has been shown to co-occur with a variety of negative correlates in adolescents, and might belong to a cluster of risk behaviors. However, as obesity becomes more common in adolescents, weight loss strategies are in greater and greater need. Perhaps weight loss dieting could be a reasonable, health-promoting behavior among overweight or obese adolescents, while simultaneously carrying health risks for those not overweight and thus not “in need of” dieting. Alternatively, dieting may carry similar risks regardless of weight status. The goal of the current study was to examine correlates of dieting in overweight and non-overweight youth utilizing a large, community sample.

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Methods 

The data for this study were drawn from Project EAT (Eating Among Teens). In brief, the Project EAT survey has a 221-question classroom-administered survey assessing nutritional, weight-related, and psychosocial factors developed based on existing instruments, with input from multidisciplinary experts in adolescent health and focus groups with youth. Participants were 4746 students in public high schools and middle schools in the greater Twin Cities area of Minnesota. The overall student response rate was 81.5%. The survey was administered by trained research staff in one 90-minute or two 50-minute class periods. Measured heights and weights were obtained by trained research staff in a private area. Approval was received from the Institutional Review Board and the consent processes were approved by each school district's research board.

Measures 

Weight status 

Height was measured without shoes, and weight was measured in street clothes without heavy outerwear; from these measurements, body mass index (BMI; weight [kg]/height [m2]) was calculated. Because 11% of participants were missing observed height and weight data, self-reported height and weight were substituted in these cases to reduce the missing proportion to 3%, as the self-reported and observed measures were highly correlated (r = .87, p < .001). Gender- and age-specific definitions for underweight, normal weight, and overweight were based on growth charts from the Centers for Disease Control and Prevention [28]. For the present study, subjects classified as underweight (BMI < 15th percentile) or average weight (BMI 15th to < 85th percentile) were grouped as “non-overweight,” and those moderately overweight (BMI 85th to < 95th percentile) or very overweight (BMI ≥ 95th percentile) were grouped together as “overweight.”

Dieting for weight loss 

Dieting for weight loss purposes was assessed using the question, “How often have you gone on a diet during the last year? By diet, we mean changing the way you eat so you can lose weight.” Response options included: “never,” “1–4 times,” “5–10 times,” “more than 10 times,” and “I am always dieting.” Students endorsing any dieting in the last year were classified as dieters.

Extreme weight control behaviors (EWCB) 

The prevalence of EWCB was assessed with the question, “Have you done any of the following things in order to lose weight or keep from gaining weight during the past year?” for the following behaviors: (1) took diet pills, (2) made myself vomit, (3) used laxatives, or (4) used diuretics. Students endorsing the use of one or more of these methods were classified as using EWCBs.

Body satisfaction 

Body satisfaction was assessed using a previously described 10-item scale [29] assessing satisfaction with separate body parts and characteristics. Responses were summed to create an overall score (range 10–50, with higher scores indicative of greater body satisfaction). Cronbach's alpha for the composite score was .93 for boys and .92 for girls. For the present analyses, the lowest quartile was considered to have “body dissatisfaction.”

Depressive symptoms 

Depressive symptoms were assessed using a seven-item scale including fatigue, sleep disturbance, appetite change, dysthymic mood, hopelessness, feeling tense/nervous, and worry [30]. The response options “not at all,” “somewhat,” or “very much” were coded 1, 2, or 3, respectively, yielding a scale range of 6–18, with higher values indicating more severe depressed mood. Cronbach's alpha was .76 for boys and .75 for girls. The top quartile of respondents was considered to have “high depressive symptoms” for the current analyses.

Self-esteem 

Self-esteem was measured using six items excerpted from the Rosenberg Self-Esteem Scale [31]. The items were scored 1–4, yielding a composite score of 6–24; Cronbach's alpha was .78 for boys and .78 for girls. The lowest quartile of respondents was considered to have low self-esteem for the current analyses.

Substance use 

Use of alcohol, cigarettes, and marijuana was each assessed with a question asking “How often have you used the following during the past year?” Students responding “never” were classified as non-users; students responding “a few times” or higher frequency were classified as users.

Other variables 

Demographic variables for the analysis included the following: (1) Race/ethnicity was assessed with one question: “Do you think of yourself as (a) White, (b) Black or African-American, (c) Hispanic or Latino, (d) Asian-American, (e) Hawaiian or Pacific Islander, or (f) American Indian or Native American.” Respondents were grouped either as white or non-white for multivariate analysis. (2) Socioeconomic status (SES) was based on the highest educational level completed by either parent. When this information was missing (n = 1058), eligibility for public assistance, eligibility for free or reduced cost school meals, and parental employment status were used to estimate five levels of SES [32], [33]. (3) School level was defined as middle school (grades 7 and 8) versus high school (grades 9–12).

Statistical analysis 

Chi-square test of significance was used to identify differences in the proportion of each dependent variable by overweight status. Multivariate logistic regression was used to calculate the odds of each dependent variable (separately) for dieters compared to non-dieters. Models were stratified by gender and by overweight status, and control for grade level, white race, and SES. Interaction terms were also added to test the interaction of dieting and overweight status, to determine if the associations between dieting and each dependent variable were significantly different for overweight versus non-overweight participants. A significance level of p < .05 was set for all analyses. SAS version 8.2 was used for all analyses.

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Results 

The weight status of the sample and the frequencies of dieting for weight loss, depressive symptoms, EWCB, body dissatisfaction, self-esteem, and substance use are shown in Table 1. The sample was evenly split by gender (2357 girls, 2377 boys) and was ethnically diverse, with 48.5% of the adolescents white, 19.2% Asian-American, and 19.0% African-American. SES was similarly diverse: 50.0% of the sample was middle or upper middle SES, 36.2% low or lower middle SES, and 13.8% high SES. Two thirds of the sample was of high school age. The majority (68.2%) of the sample was classified as non-overweight, with 31.8% overweight. Weight loss dieting was common, endorsed by 55.2% of girls and 25.9% of boys.

Table 1. Characteristics of the sample
CharacteristicsTotal n = 4734Adolescent girls n = 2357Adolescent boys n = 2377
n(%)n(%)n(%)
Weight status
Non-overweight3132(68.1)1535(67.4)1597(68.9)
Overweight1464(31.9)744(32.6)720(31.1)
Dieting for weight loss1886(40.5)1282(56.2)604(25.9)
ECWB (present)394(8.5)287(12.4)107(4.6)
Body dissatisfaction1039(23.2)728(32.5)311(13.9)
High depressive symptoms1336(30.0)855(38.4)481(21.6)
Low self-esteem650(14.8)429(19.7)220(10.0)
Tobacco use1396(31.6)718(32.7)678(30.6)
Alcohol use1701(38.6)819(37.4)882(39.9)
Marijuana use955(21.7)417(19.1)538(24.4)

For weight status, non-overweight = < 85 percentile BMI, overweight = > 85 percentile BMI.

The relationship of health risk behaviors and psychosocial factors to weight status by gender is shown in Table 2. Overweight adolescents were roughly 1.5–3 times as likely as non-overweight adolescents to report dieting, EWCBs, and body dissatisfaction. Rates of depressive symptoms were also modestly elevated in the overweight participants. Low self-esteem and tobacco, alcohol, and marijuana use were not more common in the overweight group, however.

Table 2. Relationship of health risk behaviors and psychosocial factors to weight status by gender
BoysGirls
Non-overweight (%) n = 1580Overweight (%) n = 706pNon-overweight (%) n = 1523Overweight (%) n = 738p
Dieting15.448.9<.00146.471.4<.001
EWCB4.05.9.0389.817.5<.001
Body dissatisfaction8.725.2<.00124.846.5<.001
Depressive symptoms20.324.5.02736.641.2.039
Low self-esteem9.211.1.15618.221.3.086
Tobacco use30.630.9.89032.633.1.666
Alcohol use39.441.4.38238.634.7.103
Marijuana use25.222.6.19418.719.2.778

EWCB = Extreme weight control behaviors.

Girls engaging in dieting were significantly more likely than non-dieting girls to have EWCB, low self-esteem, body dissatisfaction, high depressive symptoms, and alcohol, tobacco, and marijuana use (Table 3). Similarly, in boys, EWCB, low self-esteem, body dissatisfaction, and high depressive symptoms were more common among boys who diet than those who didn't. Marijuana use in boys, conversely, was more common among non-dieters than boys who dieted.

Table 3. Relationship of health risk behaviors and psychosocial factors to dieting status by gender
BoysGirls
Non-dieters (%) n = 1697Dieters (%) n = 589pNon-dieters (%) n = 1027Dieters (%) n = 1234p
EWCB2.2011.6<.0012.920.1<.001
Body dissatisfaction8.629.0<.00114.746.8<.001
Depressive symptoms19.029.5<.00127.747.1<.001
Low self-esteem7.318.0<.00110.427.0<.001
Tobacco use31.528.5.18324.938.9<.001
Alcohol use40.937.1.10931.142.55<.001
Marijuana use25.820.4.00116.021.6<.001

EWCB = Extreme weight control behaviors.

When dieters and non-dieters were compared using logistic regression, dieters tended to have significantly elevated odds ratios (ORs) for several psychosocial factors and health risk behaviors among both non-overweight and overweight participants (Table 4). Girls who reported dieting had elevated ORs for EWCB, low self-esteem, body dissatisfaction, and depressive symptoms, plus tobacco use and alcohol use. For boys, these included EWCB, low self-esteem, body dissatisfaction, and depressive symptoms. These relationships appeared strongest for EWCB; for example, with ORs of 9.31 for non-overweight girls, and 6.82 for overweight girls. For the other variables where elevations were seen, ORs generally ranged between 1.5–3.5 for both boys and girls.

Table 4. Odds ratio (OR) for dieters versus non-dieters by weight status and gender*
BoysGirls
Non-overweight OR (CI)Overweight OR (CI)Non-overweight OR (CI)Overweight OR (CI)
EWCB6.28(3.61–10.95)a3.75(1.74–8.06)a9.31(5.53–15.67)a6.82(3.26–14.26)a
Body dissatisfaction2.44(1.58–3.75)⁎3.64(2.45–5.42)⁎5.26(3.98–6.94)⁎3.19(2.21–4.62)⁎
Depressive symptoms1.68(1.20–2.35)⁎1.65(1.14–2.40)⁎2.43(1.94–3.04)⁎1.76(1.23–2.52)⁎
Low self-esteem2.11(1.37–3.24)⁎2.92(1.68–5.07)⁎3.24(2.41–4.37)⁎2.82(1.67–4.75)⁎
Tobacco use1.02(.73–1.41).90(.63–1.27)1.89(1.50–2.38)⁎1.75(1.18–2.59)⁎
Alcohol use.98(.72–1.35).91(.66–1.27)1.70(1.35–2.13)⁎1.60(1.09–2.35)⁎
Marijuana.87(.60–1.25).87(.59–1.28)1.23(.93–1.62)1.54(.95–2.48)

EWCB = Extreme weight control behaviors.

CI = 95% confidence interval.

a Controlling for grade level, white race, and SES.

⁎ p < .05.

Interaction models suggest that the increased risks associated with dieting were similar for overweight and non-overweight participants. Observed ORs did not differ significantly between non-overweight and overweight boys, or between non-overweight and overweight girls, except for body dissatisfaction in non-overweight (OR = 5.26) versus overweight girls (OR = 3.19). Thus, the odds of having a higher degree of body dissatisfaction were significantly greater for non-overweight dieters than overweight dieters.

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Discussion 

While dieting has been suggested to be detrimental for teens of healthy weight but beneficial for those who are overweight [34], findings from the present study show that the risks associated with dieting appear similar for overweight and non-overweight teens. The psychosocial and behavioral risks of dieting, therefore, may outweigh the potential benefits, even for overweight teens. The current study is relatively unique in examining the interaction of weight status and dieting status with regard to health risk behaviors. Notably, this association with adverse health behaviors was independent of weight status. In other words, the attendant health risks of dieting appear to be similar for youth at relatively low and relatively high BMIs.

The finding that dieting tends to co-occur with a number of health risk behaviors and measures of diminished emotional well-being regardless of weight status has substantial public health significance. Overweight and obesity are increasingly prevalent among adolescents, and many treatment and prevention strategies are being developed. These span the gamut from primary prevention efforts such as changing exercise patterns and food intake or providing weight report cards to a variety of obesity treatment strategies. Many of these interventions include some degree of diet change for weight loss. An important question certainly exists as to whether these are effective, but independent of that question, these data suggest that such dieting efforts are associated with higher rates of health risk behaviors and poorer emotional adjustment even in adolescents who are overweight. As such, recommendations for dieting as a weight-control measure may need to be reconsidered and perhaps eliminated, particularly if the results of this study are replicated among adolescents engaging in supervised dieting for weight loss.

This study replicates work showing that a variety of adverse psychosocial factors, including unhealthy weight control behaviors, low self-esteem, body dissatisfaction, and depressive symptoms were more common in overweight than non-overweight teens [35]. Previous studies have also shown dieting to be a more common behavior among overweight than non-overweight adolescents [22], [23], [24]. Others have reported higher rates of health risk behaviors including smoking among adolescents who diet [15], [16], [17], [18], [19], [36], [37], [38].

There are several strengths to the current study, including the large, ethnically and socioeconomically diverse population and relatively high participation rate. One limitation is the cross-sectional nature of the study design. Thus, one cannot conclude with certainty that dieting causes the adverse factors that were found to co-occur with it. A second limitation is that information about the nature and duration of dieting attempts was limited. The dieting behaviors these adolescents engaged in might differ from supervised weight loss programs in nature, adverse correlates, and perhaps effectiveness. There is evidence to suggest that differing intensities of dieting have different correlations with other health-related behaviors [14], [15]. Similarly, motivations for dieting behavior were not assessed. It remains possible that the health correlates of dieting to obtain a thin ideal body shape might differ from the correlates of dieting to avoid medical problems. A final limitation is that 11% of subjects had self-report rather than interview, data for height and weight. However, in this data set, correlations of self-report and measured health and weight have ranged from .800 to .964 [39]. The analyses were repeated excluding subjects with self-report data for BMI, and the results did not change.

These findings have several implications for future research. First, the relationships observed here are cross-sectional and should be examined using prospective designs. Second, more intensive assessment of dieting activities is indicated to attempt to clarify whether some carefully planned dieting behaviors might be beneficial and not be associated with adverse correlates. The adverse correlates of dieting identified here might not extend to supervised weight loss settings.

These findings also have policy implications. They suggest that obesity treatment and prevention efforts aimed at adolescents might well benefit from de-emphasizing dieting behaviors. Also, although dieting was much more common in overweight than non-overweight youth, dieting for weight loss was reported by approximately 30% of non-overweight youth. This figure underscores the importance of addressing current societal beliefs regarding the value of thinness that appear to put adolescents at risk for the development of disordered eating.

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Acknowledgments 

This word was supported in part by grant MCJ-270834 (D. Neumark-Sztainer, principal investigator) from the Bureau of Maternal and Child Health (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services, US Public Health Service; and grant K-02 MH65919 (SJC).

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PII: S1054-139X(05)00286-7

doi:10.1016/j.jadohealth.2005.05.019

Journal of Adolescent Health
Volume 38, Issue 5 , Pages 569-574, May 2006

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