Promoting Self-Esteem and Positive Body Image in ...



Promoting Self-Esteem and Positive Body Image

in Overweight and Obese Girls

Meaghan M Eddy

University of Cincinnati

Abstract

Childhood obesity has reached epidemic rates in the United States, affecting all socioeconomic classes. At the same time, eating disorders are also on the rise. Starting in middle childhood (approximately age 8-13), girls are bombarded with media images of the ideal female. This tumultuous period of development is frequently characterized by plummeting self-esteem, which is significantly compounded in the overweight and obese child. Health providers of girls in this age group are in a position to identify those at higher risk and guide the child and parent to available resources. This article will review literature on the relationship of low self esteem, body image, and obesity in females in middle childhood through adolescence; and the benefits of referring at-risk girls to varying group programs which advocate a combination of positive body image, healthy lifestyle, nutrition, and physical exercise.

Keywords: childhood obesity, self-esteem, intervention

Promoting Self-Esteem and Positive Body Image in Overweight and Obese Girls

Introduction

Obesity has reached epidemic proportions in the United States, as the percentage of adults with a BMI over 30 has exploded to 33.8% of the population (Centers for Disease Control and Prevention [CDC], 2008). When considering the adults whom fall in the 25-29 BMI range, the statistic climbs to a staggering 68.2% of the adult population (CDC, 2008). Currently, 16.9% of children ages 2-19 are above the 85th percentile in weight, labeling them as overweight or obese (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). There are specific concentrations of ethnic groups that have higher rates of obesity, with African-American females, Hispanic males, and Native Americans males and females being the groups with the highest rates (Ogden et al., 2010). American Academy of Pediatrics recognizes obesity as the most chronic health problem of American children. The often blamed culprits in the rise of obesity are a combination of inexpensive calorie dense foods, a more sedentary lifestyle, and inaccessibility of safe avenues for physical activity in high risk populations (Raj & Kumar, 2010). A direct link between obesity and development of issues such as cardiovascular disease, endocrine disorders (primarily diabetes mellitus type II and metabolic syndrome), pulmonary disorders, renal disorders, orthopedic disorders (primarily arthritis) has been well established (Raj & Kumar, 2010). At current rates, one in three children born in the year 2000 is expected to develop type II diabetes mellitus, and will be a part of a generation that, at current obesity rates, is expected to have a shorter life expectancy than their parents (White House Task Force [WHTF], 2010) – by as much as two to five years (Girl Scout Research Institute [GSRI], 2004).

Jasik & Lustwig (2008) have identified the time period of ages 9 to 12 as being both a key time period for development of excessive adiposity, and the most challenging time period to stage intervention in regards to rapidly changing cognitive and emotional development. The highest increase in skin fold thickness was noted to occur between thelarche and the onset of menarche, with a stabilization period through middle adolescence—suggesting that weight gained during this time period translates to a greater risk of obesity carrying over into adulthood (Jasik & Lustig, 2008). Higher levels of adiposity translates to higher systemic levels of estrogen in girls, and an earlier onset of thelarche (Jasik & Lustig, 2008). Early breast development compared to peers has been noted to cause social isolation and subsequent low self esteem (Jasik & Lustig, 2008). Obesity in adolescent females is strongly correlated with poor self-esteem and poor body image, which can lead to depression, anxiety, disordered eating, substance abuse, social isolation, and suicidal ideation (O’Dea, 2008). These issues in combination with the typical decline in physical activity and worsening of one’s diet noted during adolescence, a self-perpetuating cycle is created to produce significant psychosocial ramifications in addition to the eventual physical complications of obesity (Jasik & Lustig, 2008).

Role of Culture and Media

According to McClure, Tanski, Kingsbury, Gerrard, & Sargent (2010), self esteem represents the capacity of one to feel worthy of happiness and is an important determinant of adolescent mental health and development. One in three girls has a distorted interpretation of her appearance—whether it be that she feels she is overweight when she is normal, or she feels she is normal when she is overweight (GSRI, 2004). General risk factors for low self-esteem are adolescence, female gender, low socioeconomic status, nontraditional family structure, having health care/ special needs, exposure to school bullying, parental aggravation and family stress, elevated BMI, sedentary behavior, and higher rates of television viewing (Strauss, 2000). Pre-puberty, a child’s self-esteem is not significantly tied to BMI; however, by ages 13 to 14, there is a significant negative correlation (Strauss, 2000). Protective factors for preservation of self-esteem are physical activity, perception of good health, family communication and closeness, authoritative parenting, perceived teacher support, being part of a religious community, and feeling safe at school (McClure et al., 2010). McClure et al. (2010) found that obesity is the most strongly correlated, modifiable risk for low self-esteem in pubescent girls. This reinforces the importance of efforts to prevent and manage childhood obesity by parents and clinicians.

Promoting good self esteem and a healthy body image in a young girl is not simplistic task. In a study conducted by Wang & Vuegelers (2008), low self-esteem did not appear to be a statistically significant contributing factor to the development of obesity, rather a primary result of it. As identified in the study conducted by GSRI (2004), the most important issue to school age and adolescent girls is to be “normal healthy” ie, to feel like they fit in with their peers. The GSRI (2004) states that girls define health as an absence of negative behaviors—such as avoiding drugs and alcohol. There is clearly a lack of knowledge in the girls surveyed about positive behaviors to promote good health.

Girls of this age group are highly influenced by the values of pop culture and the peer group with no desire to deviate for the prescribed gender ideals. Girls are bombarded with pop culture’s presentation of the ideal female image in television, movies, magazines, and the internet. The media exposes girls today to a much higher amount of advertising than previous generations. Girls are presented with contradicting messages by the media; which may be partially to blame for the vague responses given during the GSRI (2004) survey. Girls are encouraged to love themselves but they are also told that being overweight is undesireable (GSRI, 2004). McClure et al. (2010) report that girls view their bodies as a means of attracting others; in contrast to boys, who view their bodies as a tool to operate in their environment. This value becomes challenged when a girl’s body does not fit the ideal of what is portrayed as attractive—a goal which is unattainable by a vast majority of females in general.

Even earlier than the influence of peers and the media is the influence of the family unit upon body image. The most impacting relationship in a young girl’s life is the mother-daughter relationship. The susceptibility of the adolescent girl to peer and pop culture pressure is largely dependent upon maternal values, actions, and the relationship she holds with her daughter (GSRI, 2004).

Specific qualities identified as posing the greatest risk for development of psychosocial complications of obesity are those of the Caucasian race, those who have adopted ideas from a poor maternal body image, those who have a stressed or lack a mother-daughter relationship, and those who have a low level of physical activity (Franklin, Denyer, Steinbeck, Caterson, & Hill, 2006). It is noted that African-American [AA] girls often do not experience as extreme of a downward spiral in self-esteem as has been noted in their white, non-hispanic peers (Wang, Liang, & Chen, 2009). Identifying oneself with an ethnic group has been theorized as protective against low self esteem. This theory is demonstrated in a study conducted by McClure et al. (2010) which found higher levels of overweight and obesity in the female Hispanic and AA populations in the US, yet these girls have the highest self esteem and the most positive body image on average. The study noted that among low income AA girls, there is a very inaccurate perception of BMI, especially in those greater than the 85th percentile (McClure et al., 2010). Compared to Caucasian girls, pre-pubescent AA girls are much less likely to be concerned with being overweight, to report that they feel that they are overweight (regardless of actual BMI), and feel pressured to be thin (McClure et al., 2010). Though this does change as the child reaches puberty, the AA girl continues to report less desire for thinness than her Caucasian counterpart (McClure et al., 2010) It is possible that this is due to a cultural acceptance of “curvy” women, resulting in the positive influence of women who are confidant in their appearance. These findings warrant further investigation as to whether it is the values of the particular ethnic group or the sense of “belonging” that is protective (McClure et al., 2010).

Which Treatment Takes Precedence?

The “Let’s Move” campaign states that children with a BMI greater than the 95th percentile have a reported quality of life similar to a child with cancer (WHTF, 2010). The question is not whether an intervention is needed; it is what would be the best approach. In a study of 448 youths in the Chicago area, and astonishing 24.2% of participants (both male and female) reported feeling bad about his/her body weight, regardless of BMI, with the rate rising to 62.9% in the obese female category (Wang et al., 2009). The reports of poor self-esteem in almost one in four youths, regardless of weight status, eludes to a wide spread decline in body image in this age group that is only magnified by obesity.

In dealing with young adolescents, the future threat of health problems is not a developmentally graspable concept. According to Piaget’s developmental stages, one is unable to completely grasp these concepts until the late teenage years- a timeframe at which a majority of the psychological stigma of obesity has already occurred. Perhaps the most important concern to address at a young age is the psychosocial effects, as this is often the most important aspect to a young patient (O’Dea, 2006).

The question posed to the medical community is in regards to what is the appropriate approach to this issue. It is undeniable that the medically preferred outcome would be total prevention of obesity from the start, therefore eliminating subsequent complications. However, it has been noted in several studies that programs with a primary focus on exercise as a means to increase self esteem actually are detrimental to the body image of the participants, and have not produced a sustained, significant reduction in BMI (O’Dea, 2009; Wang et al., 2009; Klesges et al., 2010). O’Dea (2009) theorizes that the most effective model would focus primarily on building self-esteem, with secondary promotion of a healthy attitude towards diet and exercise. As the time period of greatest potential for weight gain also coincides with a psychological immaturity, it is ascertained that the best course of action in girls is an early intervention to promote self-esteem and positive body image; starting just before the onset of thelarche—around the age of 8 or 9 years. Empowering a young girl through this tumultuous time period should take precedence, with a gradual increase in focus on nutrition and physical activity as the patient enters middle adolescence after menarche, or approximately 13-14 years of age. At this point, the patient’s weight gain will have stabilized, and the patient will have become more emotionally mature.

Role of the Primary Care Provider

First and foremost, it is the provider’s responsibility to screen all patients for depression and suicidal ideation. There is a fine line between the typical “sullen” adolescent and one that may experience clinical depression. The PCP may desire to treat this type of intervention as preventative care for the patient’s mental health. Realistically, the primary care provider does not have adequate time during a typical appointment to address every health issue as well as identify and counsel a child that is identified as one who may potentially benefit from an intervention. As one does not generally address acute issues and preventative care in the same visit, the provider may desire to schedule an additional appointment with the patient and parents to discuss self-esteem and body image. The provider must assess family attitudes towards health and the motivation level of the family unit to support the patient’s participation. While many areas do offer programs which are free or with minimal cost, it is prudent that that provider be mindful of other costs to the family such as transportation. Resources vary by geographic location, but many areas have several programs to choose from.

Review of Resources

Available programs vary in intensity and primary focus. It is essential that the provider establish the patient’s values and goals before recommending a specific resource. Available approaches range from patient-centered, motivational interviewing between the patient and the provider to participation in community wide programs. Regardless of the approach to intervention, enforcement of the idea that a healthy lifestyle is worth leading for psychosocial benefits appears to be more effective than the promotion of health based upon prevention of disease later in life.

Motivational Interviewing

Motivational Interviewing [MI] is based upon the idea that obesity is maintained by dysfunctional cognitions and beliefs (Walpole, Dettmer, Morrongiello, McCrindle, & Hamilton, 2011). The interviewer must identify, evaluate and restructure the maladaptive cognitions and beliefs. This type of intervention is completely dependent upon the client’s desire to change (Walpole et al., 2011). MI has shown to work with the adult population, but little research has been conducted with youths. This particular intervention would be most beneficial for the older adolescent, who will be more self-motivated. Of benefit, this is a code-able intervention for the primary care provider, does not require referral and outside expenses to the family, and is minimally invasive (Walpole et al., 2011). This tool may be useful as a primary intervention.

School-based Health and Wellness Programs

In a survey conducted by Wilson (2007), adolescents relayed that their ideal program would include a group of peers, would take place during school hours, would involve physical activity that is “fun”, and did not feel like their family members must participate directly in the program, though family support outside the program was valued. Many schools have begun to address body image and self-esteem around the 5th grade level in school based programs. Pros of this style of program are that the entire peer group would be included in the intervention, but research has shown that it is imperative that the values set forth in the intervention also be adopted within the family unit for the intervention to make a significant impact on the child (Lubans et al., 2010). In one study, labeled the “NEAT girls”, an intensive, school-based program in Australia, targeted girls in disadvantaged secondary schools who were identified as being less active. The researchers found that their program was beneficial in improvement in body image of participants; however, no significant reduction in BMI was noted between the intervention and control groups. It is theorized by the researchers in this study that parental involvement in the program may have led to a significant impact on BMI, while preserving the observed improvement in body image (Lubans et al., 2010).

Extracurricular, female specific programs

Extracurricular, female specific programs have had significant impacts on the attitudes of the adolescent participants. This style of intervention generally has a more tailored program to participants’ needs, and a lower leader to participant ratio than school based programs. Premises behind many of the extracurricular programs is to first address the issue of poor self esteem and body image, with a secondary emphasis in some groups on increased physical activity. Many studies have reported that noncompetitive physical activity improved feelings of self-worth, citing that girls who participate in any kind of physical activity reported feeling good about themselves, regardless of weight status (Lubans et al., 2010; Klesges et al., 2010; Neumark-Sztalner et al., 2010). Literature was reviewed for Girl Scouts of America, Girls on the Run, New Moves, GEMS, GoGirlGo, and Loozit programs. The programs vary from a week long summer camp (GoGirlGo) to potential regular involvement up to age 18 (Girl Scouts of America). Curriculum varies by group and by geographical locations, therefore, the provider must be familiar with local groups. Creators of the GoGirlGo program cite that success of extracurricular programs lays in Walker’s developmental intentionality (Warner, Dixon, & Schumann, 2009). Walker’s (2006) theory states that a program will have the greatest developmental outcome if it is tailored to the essential needs and the inherent nature of a particular youth. Evidence of this is supported in follow up on participants in the GoGirlGo week long program. While many studies state that it is believed that a program would have been more effective had it extended for a longer time period, participants in the week long GoGirlsGo program relayed that they felt empowered and had fun in the process (Warner et al., 2009). It is theorized by the authors that the program’s success was due to tailoring of discussion topics to participants and the mentor having a pre-existing relationship with the participants—establishing a level of trust prior to the camp (Warner et al., 2009).

The GEMS program was specific to AA girls ages 8-10 (Klesges et al., 2010). The interventions were based at local YMCAs, and the interventionists were AA women—adults who would be the closest representation of a mother-daughter relationship. The participants met weekly for 14 weeks and then monthly for the remainder of the two years. The intervention group developed goals to eat a balanced diet, decrease sedentary behaviors, and increase physical activity. Psychological interventions included positive reinforcement, social support, and goal setting. Caregivers for the participants were encouraged to participate by increasing the availability of healthy foods at home. The control group was meant to improve self-esteem and social efficacy only, and didn’t involve the family unit. Despite a rather intensive, and well planned out study, the researchers found that there was no significant prevention of weight gain among intervention participants versus the control group (Klesges et al., 2010). The researchers theorize that an effective obesity prevention program in this particular population may be especially difficult due to the social and environmental contexts in which these girls live (Klesges et al., 2010).

Family Driven and Community Wide Initiatives

Perhaps the most difficult interventions to accomplish but potentially resulting in the greatest changes are family driven and community wide programs. NEAT girls, GSRI, Let’s Move, and GEMS all theorize that the most important participants are the child’s parents—as they are often the ones preparing meals, and can lead by example with positive attitudes and increased physical activity (Klesges et al., 2010; GSRI, 2008; Lubans et al., 2010; WHTF, 2010).

Perhaps the largest health initiative would be the campaign that is front lined by first lady, Michelle Obama. The healthy living campaign, titled “Let’s Move” is a comprehensive program which addresses physical preventative measure for childhood obesity from the mother’s prenatal care, forward (WHTF, 2010). The program is much like the campaign against smoking—attempting to create an environment in the US where slovenly behaviors and obesogenic foods are considered socially taboo. This program focuses mostly changes to preventative measures to be taken on by federal, state, and private sectors; and on the lowest level, how parents raise their children. This program does not specifically address interventions for the social stigma of obesity, rather, it aims to decrease the psychosocial side effects by eliminating the cause. The goal of the program is to return the childhood obesity rate to around 5%-- the average that was last recorded in 1972 (WHTF, 2010). The goals of this initiative are what ultimately need to be accomplished in this country to better the public’s general health, but it does provide guidelines for psychosocial support to be provided in the present.

Recommendations

Perhaps the best intervention is a combination of a family driven program with enrollment of the patient in a female specific extracurricular program which utilizes the leadership of strong, healthy women of all ages. The greatest potential for long term changes is found in family driven interventions, but adolescent girls crave interaction with peers—aiding in a sense of social acceptance in the peer group. The provider shall base recommendations upon the social background of the patient, financial constraints, and goals set forth by the patient and family. Above all, the most successful intervention will be one in which the patient feels invested (Warner et al., 2009). By encouraging the participation of patients in early interventions, the provider is not only curbing the risk for future health problems of the patient, but the provider is also helping to shape the ideas and attitudes of the future generation but creating strong role models and mothers.

Conclusions

The inverse relationship between self-esteem and BMI escalates as young girls enter the tumultuous years of puberty. Though this phenomena does not effect all ethnic groups equally, plummeting self esteem is a widespread occurrence in this age group, and without intervention may lead to issues such as substance abuse, depression, anxiety, social isolation, and suicidal ideation. The role of the primary care provider lays in quick identification of depressed and suicidal patients, and further referral to appropriate resources.

In referral to outside resources, the prudent provider will first assess the needs of the patient and family, as well as values of the family. While low self-esteem in the presence of obesity is a common occurrence, one can not assume this to always be the case, as a larger BMI is more acceptable in some cultural subgroups. Goals of motivational interviewing or referral to outside resources would be a patient reported improvement in self-esteem, body image, and self-efficacy. The patient will develop a healthy attitude towards nutrition and physical activity. Reduction of BMI should not necessarily be stressed in this age group unless the patient’s BMI poses immediate risks to morbidity as the patient may actually suffer more psychological damage through intense intervention during this fragile period of social uncertainty.

Recommendations for Further Research

Further research is needed in to area of psychosocial ramifications of obesity in general—this is an area that is far less researched than the medical complications of the disease. Cross research of into the applicability of these interventions on other populations, such as those with childhood diseases or mental illness may also be beneficial.

References

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