Self-esteem and Quality of Life in Obese Children and Adolescents a Systematic Review
Curr Obes Rep. 2017; vi(1): 63–70.
Obesity in Children and the 'Myth of Psychological Maladjustment': Cocky-Esteem in the Spotlight
Andrew J. Hill
Bookish Unit of Psychiatry and Behavioural Sciences Institute of Health Sciences, University of Leeds School of Medicine, Level x, Worsley Building, Clarendon Fashion, Leeds, LS2 9NL Great britain
Abstruse
Purpose of Review
There are contrasting views regarding the psychological well-being of children with obesity. Responding to limitations of existing evidence, Jane Wardle in 2005 argued for a 'myth of psychological maladjustment'. This review looks again at self-esteem.
Contempo Findings
The different characterisations of self-esteem each offer value. Global self-esteem is reduced in virtually all studies of youth with obesity. Dimensional self-esteem reveals physical appearance, athletic and social competence as the most afflicted areas, confirmed past inquiry that has operationalised depression cocky-competence. Children with obesity are also more likely to be victimised by their peers, generally and for their fatness. Victims who bully others appear to preserve some aspects of self-esteem.
Summary
A relatively small proportion of youth with obesity has low self-esteem, but those with severe and persistent obesity are specially compromised. Weight loss is only weakly associated with improved cocky-competence suggesting the value of resilience and nugget approaches to improving well-being.
Keywords: Obesity, Children, Adolescents, Self-esteem, Victimisation, Peer relationships
Introduction
One of Jane Wardle's early interests was in children with obesity, their cocky-perception and self-esteem [one, ii]. This was commensurate with her broader regard for the needs of people with obesity, seen in her driving the establishment of the charity Weight Concern. At that time, I was also working and publishing on the self-perception of children with obesity and have connected this involvement (while Jane's research interests and outputs proliferated). One newspaper that stands out for me, and that I come across regularly cited past others, was written by Jane with Lucy Cooke in 2005 [three]. If the championship was benign, 'The affect of obesity on psychological well-being', the conclusion was non. They wrote 'The persistence of the myth of psychological maladjustment of overweight and obese children is striking'.
The paper was a review of contempo publications on body dissatisfaction, self-esteem and low in children and adolescents with obesity. Interestingly, in the same year, Carl-Erik Flodmark published a short overview of the literature titled 'The happy obese kid' [four]. Both publications shared the message that outside of a clinical environment, very few children with obesity are either depressed or have low cocky-esteem. Neither of these publications sought to dismiss children with obesity who are in distress and in need of help. Rather, they challenged practitioners to look again at the children they work with, not to generalise from extreme clinical experiences, to put aside preconceptions and to place factors that protect psychological well-beingness.
The literature on self-esteem in childhood obesity exemplifies the challenge of agreement the psychology of immature people with obesity. In their review, Wardle and Cooke noted the following problems [3]. Self-esteem appears poorer in clinical samples of youngsters with obesity than those from the community; so, it is unwise to generalise. Researchers rarely look beyond hateful scores on cocky-esteem measures, or whether pocket-sized differences in hateful scores between children of healthy weight and those with obesity have existent-life significance. Little effort has been directed to potential moderators or mediators of the relationship between obesity and cocky-esteem. Over the course of handling, weight loss appears poorly related to any change in cocky-esteem. I would add together that there has been niggling serious consideration of how self-esteem is conceptualised (and measured) in the context of obesity. Few authors have sought to define (and measure) low self-esteem and apply this to obesity. Furthermore, the predominant view of the relationship between obesity in babyhood and self-esteem has been unidirectional rather than dynamic. Recognising the challenge laid down by Jane (and Lucy), a re-evaluation of the literature on self-esteem in children and adolescents with obesity is timely.
Conceptualising Cocky-Esteem
Self-esteem is a long established psychological construct with a huge attendant literature. Self-esteem refers to the way that people perceive and value themselves. In more than elaborated form it is, 'the extent to which a person believes himself to be capable, significant, successful and worthy' [five]. As Emler notes in his hugely influential review, the public discourse about cocky-esteem has moved forward [6]. In electric current usage, self-esteem is virtually psychological health and identity. It is a resource and an asset. Loftier cocky-esteem is something nosotros should have by right equally it is practiced for the individual and for society.
In terms of how self-esteem is assessed, so a distinction tin can be made between self-esteem equally a generalised or global cocky-appraisal, as competence in externally (and internally) valued domains and every bit a metric of social acceptance (or likely rejection). These perspectives each accept something to say about the relationship between obesity and cocky-esteem.
Global Self-Esteem
The idea that self-esteem tin be assessed equally an evaluative attitude to the self has been attributed to Rosenberg and his scale is regarded as the golden standard in cocky-esteem research [7]. The ten-item Rosenberg self-esteem scale concerns very general evaluations of oneself and yields a unmarried score, a sum of positive statements. Its popularity is in part due to its simplicity and brevity.
Unsurprisingly, this scale is prominent in obesity enquiry. In a meta-analysis looking at global self-esteem in all age groups, Miller and Downey found an outcome size of −0.36 (95% CI −0.33 to −0.40), a robust but small to moderate sized relationship [8]. This confirms the difference in global cocky-esteem scores between people of salubrious weight, who are overweight, and with obesity.
Important influences on the strength of this relationship were age and gender. The correlation betwixt weight and self-esteem increased from −0.12 to −0.22 and −0.28, in children, adolescents and young college-age adults, respectively. In addition, the relationship was stronger in females (−0.23) than males (−0.09). More recently, a systematic review of studies comparing youth with obesity and salubrious weight controls found lower global self-esteem scores in those with obesity in 17 of the 21 included studies [nine•]. The four exceptions had a feature in common. They all reported on non-white indigenous groups: either samples from Asia or minority ethnic groups in the USA. The review authors urged caution, however, noting that there are other studies of youth and adults from the aforementioned countries and ethnicity/income groups that do bear witness lower cocky-esteem in individuals with obesity [10].
Perceived Cocky-Competence
The global perspective of self-esteem is in fact pre-dated by an elaborated conceptualisation. The representation of self-esteem equally the ratio of a person's successes to their pretensions has been attributed to William James [6]. Hither, cocky-esteem is a personal evaluation of competence in areas viewed as important. So, there are 2 parts to this formulation of self-esteem: multiple domains in which the cocky is evaluated and a likelihood that some domains are more of import than others. Indeed, information technology is the discrepancy between competence and importance that defines overall self-worth. Only when a person feels depression competence in an area of high importance is their overall self-worth jeopardised.
There are just a handful of ordinarily used multidimensional measures of self-esteem for children and adolescents [11]. Information technology is Susan Harter who has washed about to develop the Jamesian conceptualisation and assessment of perceived self-competence [12]. She argues that for children, the necessary domains of competence are set by parents (scholastic competence and behavioural conduct) and peers (physical appearance, social and athletic competence). These domains expand in range through adolescence into machismo, incorporating attributes such as job competence, romantic appeal and a sense of sense of humor.
We conducted a systematic review of multi-competence assessments in young people with defined obesity. Studies that had only looked at overweight were excluded every bit nosotros were interested in what the literature had to say specifically about the self-competence of those with obesity. There were 17 studies, of which nine were cross-sectional and seven weight management interventions [xiii]. Almost had used Harter's questionnaires. All of the studies that assessed concrete appearance and athletic/concrete competence found lower scores in youth with obesity. Obesity besides impacted on perceived social acceptance, with lower scores reported in one-half of those measuring this domain. In contrast, few differences were observed in scholastic competence or behavioural behave. Global self-worth was lower in children with obesity compared with those salubrious weight in six of the nine cross-sectional studies, a finding comparable to that of the global self-esteem literature above. There were insufficient studies to detect any effects of historic period or sex activity. Too, comparisons based on race or ethnicity are infrequent in this literature. But the ascertainment that in younger (ix–12-year olds) minority children from depression-income families, all, regardless of their weight condition, had lower global cocky-worth than a reference white population [fourteen] is a reminder of the inherent complexities in this expanse.
Thus far, this literature says much more about successes than pretensions in children with obesity. The competencies included in Harter's self-perception profiles may indeed exist those most important to today's youth. Harter herself has written near how perceived concrete appearance is the number one predictor of global self-worth [15]. This is true from age five through to adulthood. It raises the event of how to help children value competencies other than appearance. But given that one mode of managing poor competence is to diminish the importance of that feature, it is surprising that perceived importance has not been more thoroughly investigated. An assessment of domain importance is included in the manuals for Harter's scales but rarely used in enquiry. Our own unpublished work suggests that for a customs sample of 12-year olds at to the lowest degree, healthy weight children and those with obesity do not differ in how important they rate appearance and athletic competencies. Even so, and in accord with the evidence presented in a higher place, they do perceive themselves very differently on these features.
Low Self-Esteem
The response format of the Harter measures permits one further and rarely reported feature of self-esteem: the assessment of low cocky-esteem. As acknowledged above, previous attending has focused on hateful calibration values that are statistically different merely of questionable functional difference. Children completing Harter's assessments go through a two-stage process in answering each question. The first requires them to identify with either a high or low self-competence characterisation. The second asks whether this description is 'sort of' or 'really' true for them. By setting a scale value at the point where a kid indicates that they are similar to the low competence description, so the proportions of depression (and high) competence children can be compared beyond weight groups.
In a land-broad survey of 9–13-year olds from New South Wales, Australia, we found that perception of physical appearance was particularly affected, with 63% of girls and 33% of boys with obesity identifying with the delineation of a physically unattractive child [sixteen]. In contrast, the proportion of low scorers on the global mensurate of self-worth was smaller. Although the relative risk of low global self-worth in girls with obesity was 4.1 times more than normal weight peers, only twenty% of the grouping scored in this range. Complementing this, girls with obesity were more than than five times less probable to have high global cocky-worth, something accomplished by around seventy% of their peers.
Danielsen et al., using the aforementioned arroyo to defining low cocky-esteem, also plant higher proportions of Norwegian x–13-year olds who were overweight/obese to have low concrete appearance and athletic competence [17•]. For this population sample, the difference from good for you weight children extended to low social acceptance and scholastic competence, although the proportions were smaller than observed in the Australian children.
The Looking-Glass Cocky
This rather unlike framing of self-esteem is attributed to Charles Cooley, and once again, it is long-standing and highly influential. Its basis is that our assessments of our own worth are based on the judgements we imagine others make of us [6]. Moreover, our predictions well-nigh these judgements depend upon the qualities we come across in these other people. So, what shapes cocky-esteem are not our accomplishments objectively and direct appraised, merely the anticipated judgements of these accomplishments by other people. Hence, self-esteem is what we await will be reflected by this social mirror, and the intensity of reflection depends on who we choose as our social referents.
Mark Leary has taken this social view in a particular management, one very relevant to obesity. Sociometer theory proposes that the cocky-esteem organisation evolved primarily as a monitor of social credence, the motivation being not to maintain self-esteem per se, but to avoid social devaluation and rejection [18]. He argues that people are particularly sensitive to changes in relational evaluation or the degree to which others regard their human relationship with the private as valuable, important or close. Accordingly, self-esteem is lowered by failure, criticism or rejection and raised past success, praise and events associated with relational appreciation. Fifty-fifty the possibility of rejection can lower self-esteem. Two areas of inquiry are specially relevant to youth with obesity—interpersonal relations and victimisation.
Interpersonal Relations
Sociometric procedures using peer-nominated friendships have shown piffling bear upon of being obese in community samples of chief schoolhouse aged children. Some 20 years ago, for example, young children with obesity in the UK were only as likely to be chosen as their lean peers as people to socialise with both inside and outside of school, fifty-fifty though they were judged as less attractive [xix]. The situation is likely to be dissimilar now, as has been observed in the USA. In a very large community sample of 6–7-yr olds, Harrist et al. used almost and least liked peer nominations to generate standard social preference classifications [twenty•]. Children with obesity were more likely than healthy weight children to be neglected, i.e. with few positive or negative nominations. Those with severe obesity were significantly more than likely to be rejected, i.due east. with more to the lowest degree-liked, negative nominations. Even then, more than twice as many half dozen–7-twelvemonth olds with obesity were classified as popular or average than were those rejected, neglected or controversial.
Looking at an older age grouping, information from the US National Longitudinal Study of Adolescent Wellness (Add Health) shows overweight adolescents to be over-represented in categories of no or few peer friendship nominations and under-represented in the most popular categories [21]. Virtually chiefly, they received fewer reciprocal nominations: that is, nominations past peers they themselves had nominated. Further analysis of this accomplice indicated that overweight adolescents whose friendship attempts with non-overweight peers were not reciprocated would plow to other overweight peers [22•]. Appropriately, in another and smaller sample of United states teenagers, friendship choices showed that overweight youth were twice as likely to have overweight friends as their non-overweight peers [23].
The relative failure to be named a friend by people you nominate suggests that the friendship ties of adolescents with obesity are less plentiful, potentially weaker and more directed to others with obesity. In terms of self-esteem, the peer referent for cocky-evaluation chosen by teenagers with obesity determines their social continuing: valued and held in esteem by others similarly overweight but likely rejected and and then of low cocky-esteem in the eyes of those of healthy weight.
Victimisation
Peer difficulties and rejection have been observed in young children with obesity. Past historic period five, parents of children with obesity are more likely to study peer relationship problems in their girls and boys than parents of healthy weight children [24•]. 5-year olds themselves reject story characters drawn every bit fat as people they would choose to be friends with [25•]. Rejection may be a very modest footstep from perceived victimisation.
The research evidence is unequivocal regarding the association betwixt obesity and victimisation. A meta-analysis of 16 studies and 28 effect sizes showed a significant relationship between being obese and being victimised (OR = 1.51 (1.32, 1.71)) [26•]. Most of these studies were of children aged 11 and upwards. In an interesting evolution, observations past Principal school teachers in the Netherlands and the children themselves revealed that children with obesity were more likely to be victimised by their peers but too more than likely to bully others [27•]. Indeed, in that location was a small group of children referred to as bully-victims who were both recipients and perpetrators of victimisation. Children with obesity were twice as likely to be in this category as salubrious weight peers.
The work above has examined the generalised experience of victimisation without focusing on the reason for victimisation. Relatively, little piece of work has looked specifically at weight-related victimisation in young people. We reported that some 42% of 9–12-year olds with obesity identified themselves equally fat victimised compared with vii% of their healthy weight peers [28, 29]. Interestingly, being fatty victimised was strongly associated with being victimised mostly. In other words, those fatty victimised were often those who felt victimised for other reasons too.
Of the sample of 815 English Primary and Secondary school children in these studies (440 boys, 375 girls; mean age = eleven.0 years, range 9.0–12.6), 97 (eleven.9%) identified themselves as fatty victimised and 42 (5.2%) as fat bullies. The assessment of fat victimisation was incorporated into Harter's Cocky-Perception Profile for Children using two scales directed at victimisation and bullying developed by Austin and Joseph [30]. Nosotros retained three items from each scale and adapted items to form 2 new scales specific to fatty victimisation and bullying. The effect was a fat victimisation scale (e.g. some children are often bullied for beingness fatty), a fat bully calibration (some children often tease other children virtually being fat) and two scales in which the reason for victimisation was unspecified (e.thousand. some children are often chosen horrible names by other children). Internal reliability of these scales was proficient (α = 0.72 to 0.82) and did not vary past sex or age of respondents.
Fatty victimised children were heavier and had a greater BMI z-score than those not victimised. They had significantly greater trunk dissatisfaction, and fatty victimisation was strongly associated with current dieting to lose weight, with 35.1% of those victimised currently dieting compared with eleven.6% of non-victimised children. Looking at their perceived self-competence, children fat victimised scored significantly lower on all domains, including global cocky-worth. Lower perceived social acceptance was congruent with significantly lower peer-nominated popularity (beingness nominated as someone that classmates would most like to sit adjacent to in class and/or be with at breaktime), although the mean difference amounted to less than a half nomination per child (ii.30 vs two.81). Figure i shows that fatty victimised children were more likely to receive very few peer nominations and less likely than non-victimised children to exist nominated past many peers.
Of the 97 children fat victimised, 19 (13 boys, 6 girls) fatty bullied others. A further 23 (21 boys, ii girls) reported themselves equally fatty bullies without existence victimised. There were more children with obesity in the bully-victim group (32%) than in the fat victimised (29%), fatty bullies (xviii%) or not involved group (v%). This is consistent with the report of children in holland [27•]. However, it was those fatty victimised whose risk of depression domain competence was greatest. Tabular array 1 shows that every domain was affected other than behavioural conduct (primarily at school). The relative risk of low global self-worth in fat victimised children was 5.39 (95% CI 3.40, 8.56). In dissimilarity, fat bullies were compromised only in terms of their poor behavioural conduct. Looking at perceived high domain competence, then the keen-victim group shared with those fat victimised a failure to match their peer groups' proportions of high scholastic competence, social acceptance and global cocky-worth.
Tabular array ane
Fat victimised | Fat bullies | Both fatty victims and bullies | |
---|---|---|---|
(North) | (78) | (23) | (xix) |
Low perceived competence | |||
Scholastic competence | 1.74 (i.11, ii.72) | 0.89 (0.34, 2.88) | i.19 (0.42, 3.43) |
Social acceptance | ii.97 (1.92, 4.69) | 0.23 (0.01, 3.58) | 2.32 (0.94, 5.72) |
Able-bodied competence | 2.45 (ane.72, 3.50) | 0.62 (0.16, 2.55) | 1.12 (0.39, 3.21) |
Physical appearance | ii.85 (2.07, iii.93) | 0.91 (0.31, two.64) | 1.82 (0.84, 3.97) |
Behavioural conduct | one.46 (0.78, 2.73) | 3.96 (2.16, 7.28) | iii.lx (1.78, 7.27) |
Global self-worth | 5.39 (3.40, viii.56) | 0.80 (0.11, five.54) | ii.89 (0.98, eight.53) |
High perceived competence | |||
Scholastic competence | 0.65 (0.45, 0.93) | 0.lxx (0.37, 1.30) | 0.06 (0.00, 0.89) |
Social acceptance | 0.68 (0.52, 0.89) | 0.91 (0.63, 1.31) | 0.42 (0.20, 0.90) |
Athletic competence | 0.twoscore (0.26, 0.63) | 1.eleven (0.77, i.threescore) | 0.62 (0.32, ane.21) |
Physical appearance | 0.42 (0.26, 0.66) | ane.22 (0.85, ane.76) | 0.57 (0.27, 1.21) |
Behavioural conduct | 0.79 (0.60, 1.04) | 0.17 (0.04, 0.63) | 0.51 (0.24, 1.08) |
Global self-worth | 0.51 (0.37, 0.70) | 0.79 (0.53, 1.18) | 0.32 (0.13, 0.77) |
Three additional points are noteworthy. First, while being fat-teased was more than mutual in children with obesity, over half did not place themselves equally such. We know very piffling about what has protected these children or what made the other half vulnerable. Second, our assessment of fat victimisation was directed at overt rather than relational victimisation, something consistent with the preponderance of boys in the cracking grouping. Relational victimisation is more than difficult to capture in questionnaires simply may exist extremely important in assessment of the truthful extent and consequences of fat victimisation. Third, victimisation did not impact on the perceived importance of any of these domains. In one case more, it would appear that these children were not managing their low self-esteem by modifying the importance of domains in which they judged themselves less competent. Perhaps for these pre-teenagers, the possibility of diminishing the importance of such core areas in their lives is beyond imagination. They are just too immature at this age to contemplate this.
Consequences of Weight Direction
In a review of the literature on structured weight management programmes for children and adolescents that included a measure of self-esteem, 18 of 21 studies were observed to report some end of intervention improvement in self-esteem [31]. This comeback appeared related to the following intervention components: consequent parental involvement, group-based interventions and actual weight loss.
We have previously noted the inconsistencies in associations between weight loss and self-esteem improvements in the intervention literature [13]. When interventions result in weight loss, most also observe improvements in global self-esteem and the competencies near affected, i.e. physical appearance, able-bodied competence and social acceptance [32]. It is surprising therefore that the degree of weight loss was correlated with self-esteem comeback in only 1 of the five studies that reported these associations.
Nosotros have recently reported on the outcomes of an intensive, residential weight loss plan for youth with obesity. Attendees lost 5.5 kg (−0.25 BMI z-score) during an average stay of just over 4 weeks [33•]. Weight loss was positively associated with improvements in athletic competence and physical appearance just not global self-worth. The sample size was large (Northward=303) simply the correlation coefficients small (0.13 and 0.19). At the programme start, effectually one-tertiary had depression global cocky-worth, three quarters had low competence in physical advent, simply less than 17% reported low social acceptance. Only 2.3% (due north = 7) reported low domain competency beyond all domains at the beginning of the intervention, and at that place were none past the cease of their stay. By the cease of the programme, the proportion with low global self-worth had been reduced to 16%, while those with high global self-worth increased 16.5 to 23%. Nigh of the improvement in domain competence was in the moderate range of scores, with fiddling change in the number of attendees reporting high scores [33•].
Overall, observations such as these advise that psychological do good may be as dependent on some characteristic of the environment or supportive network equally on weight reduction. In the context of grouping interventions such every bit residential programmes, these may include the daily company of others who take obesity in common, improvements in competence or self-efficacy in newly prioritised areas (such as exercising regularly), the institution of new friendships or fewer experiences of weight-related victimisation. These are experienced before adolescents notice levels of weight loss that accept either personal or clinical significance [33•].
Conclusions and Implications
The relationship between obesity and dumb well-being in youth is present but minor in overall force and varies between individuals. Children with severe and persistent obesity are specially compromised. The 'myth of psychological maladjustment' can be dispelled, although the variation in impairment should be recognised.
Consider the key constituents. Psychological features such as depression self-esteem are probable minor contributors to the evolution and maintenance of obesity, albeit with the potential to interact with other risk factors. And obesity is undoubtedly only 1 of the several influences on an individual'southward sense of self-value, admitting a potentially of import ane. Additionally, both obesity and self-esteem are resistant to change. Longitudinally, any clan volition be bi-directional, in the same mode to that proposed for the relationship between obesity and depression [34]. Bi-directionality between obesity and dumb health-related quality of life, a concept that overlaps with self-esteem, emerges in middle babyhood [35•]. Information technology follows that the pre- to early teenage years is a key catamenia for children in economically developed countries. Changing peer relationships at this age and priorities for physical attractiveness are probable to be critical.
Mood disorders and eating disorders are other markers of impaired well-beingness, alongside low self-esteem. They are undoubtedly all interrelated. Furthermore, given that obesity persists, so the negativity associated with being fat is likely to accrue. Unsurprisingly therefore, those who remain obese from early babyhood into adolescence take the highest levels of depressive symptoms [36] and binge eating [37]. This is a reminder that the priority for preventing obesity should never distract from addressing the needs of those already obese. For some, these needs are apparent from childhood and go along.
In terms of improving self-esteem, then weight loss is undoubtedly important. Just as reflected on above, the child'south environment and supportive networks are also important. As previously observed, many people with obesity, adults and children alike, have high cocky-esteem, do not suffer major low, are in well-paid employment and have practiced social relationships. This implies individual resistance or resilience. Resilience offers a different perspective to the more traditional risk gene approach, focusing on strengths rather than deficits [38•]. Information technology is concordant with an assets-based arroyo to wellness improvement that is extremely popular currently in public wellness. Avails be within individuals (self-efficacy, drive), close community (family unit and friends, intergenerational) or are organisational or institutional (housing, representation/advocacy). Identifying and developing assets, many of which are external to the private, are challenging, peculiarly in an surround rife with anti-fatty attitudes. This is consistent with the view that targeting, personalisation and relationships are fundamental to improving the way that young people value themselves [half-dozen]. It is too a perspective I am certain that Jane would have supported.
Compliance with Upstanding Standards
Disharmonize of Interest
Andrew J. Hill declares that he has no conflict of interest.
Human and Animal Rights and Informed Consent
This article does non contain any studies with human being or brute subjects performed by any of the authors.
Footnotes
This article is part of the Topical Collection on Psychological Issues
References
Papers of particular interest, published recently, have been highlighted as: • Of importance
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