Perceptions of Body Weight, Weight Management ...

JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 59, NO. 1

Perceptions of Body Weight, Weight Management Strategies, and Depressive Symptoms Among US College Students Holly Anne Harring, MSPH; Kara Montgomery, DrPH; James Hardin, PhD

Abstract. Objective: To determine if inaccurate body weight perception predicts unhealthy weight management strategies and to determine the extent to which inaccurate body weight perception is associated with depressive symptoms among US college students. Participants: Randomly selected male and female college students in the United States (N = 97,357). Methods: Data were from the 2006 National College Health Assessment. Analyses were conducted on students’ body weight perceptions, weight loss strategies, and feelings of depression. Results: Females with an inflated body weight perception were significantly more likely to engage in unhealthy weight management strategies and report depressive symptoms than were females with an accurate body weight perception. Conclusions: College women are concerned with weight and will take action to lose weight. Colleges may need to focus more on interventions targeting both diet and physical activity while also promoting positive body image.

ued to increase in children and adolescents and among both males and females.1 The prevalence of overweight among adolescents, age 12 to 19 years has increased from 14.8% in 1999–2000 to 17.4% in 2003–2004.1 This is of serious concern because obesity in adolescence is the leading predictor of obesity in adulthood.3 The college years are a time of transition for many young adults, since this is the first time that most are living away from home. With new independence, young adults are faced with the challenges of independent meal planning and food and beverage selection. Research indicates that college students typically consume a poor-quality diet that is high in fat, sugar, and sodium and deficient in fruits, vegetables and lowfat dairy products.4–7 Furthermore, recent research demonstrates differences in dietary patterns among college students according to body mass index (BMI).8 For instance, obese and overweight students have been more likely to report consuming pork, legumes, and all-meat products, whereas students who were underweight have reported consuming more cheese, green leafy vegetables, other vegetables, hot cereal, and all-dairy products.8 Furthermore, college students have been identified as a population segment that may be prone to using unhealthy weight management strategies such as fasting, diet pills, laxatives, or self-induced vomiting; these behaviors are especially prevalent in underweight and normalweight college women.9–12 The American College Health Association (ACHA) has developed a National College Health Assessment (NCHA), a survey instrument designed to collect information on a broad range of students’ health behaviors, health indicators, and perceptions.13 Summaries from the 2008 NCHA items pertaining to nutrition and weight management strategies indicate that 62.8% of females and 45.4% of males exercise to lose weight, 42.1% of females and 24.1% of males diet to lose weight, 3.3% of females and 0.6% of males vomit or take laxatives to lose weight, and 3.8% of females and 1.7% of males take diet pills to lose weight.13 Moreover,

Keywords: body weight perceptions, college students, depressive symptoms, weight management strategies

T

he prevalence of overweight and obesity is increasing among US adults. In 2004, 67% of US adults were overweight and just over 33% were considered obese compared to the 1960–1962 National Health and Nutrition Examination Study (NHANES), which estimated the prevalence of overweight to be 43% and the prevalence of obesity to be 13%.1,2 This increase in overweight and obesity transcends age, gender, and racial/ethnic groups, but is rising more rapidly among women, young adults, Hispanics, African Americans, and people with some college education.1 In addition, the prevalence of obesity has contin-

Ms Harring and Dr Montgomery are with the Department of Health Promotion, Education, and Behavior at University of South Carolina in Columbia, South Carolina. Dr Hardin is with the Department of Epidemiology and Biostatistics at University of South Carolina. Copyright © 2010 Taylor & Francis Group, LLC 43

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estimated BMI classifications based on self-reported height and weight indicated that 28.8% of females are overweight or obese and 39.4% of males are overweight or obese. However, 38% of females describe themselves as overweight whereas 30.8% of males describe themselves as overweight.13 This inaccurate body weight perception, specifically among females, suggests that body image and other normative beliefs may be influencing students’ awareness of what is considered a healthy body weight and what is considered appropriate weight management. Although programming targeted towards improving body image is needed, additional efforts by colleges and universities may be garnered to address healthy weight management strategies. In addition to rising obesity rates and the prevalence of harmful weight management strategies employed by college students, 2008 NCHA data suggest that stress is the number 1 reported health impediment to students’ academic performance, with depression and anxiety ranked number 5.13 Research on stress and food consumption suggests that continual work stress is associated with greater energy consumption, specifically increased saturated fat and sugar intake, and weight gain among restrained eaters.14 Furthermore, social situations perceived to be stressful lead to increased consumption of foods that are higher in fat, sugar, and overall more energy dense.15 In addition, research examining predictors of dieting concerns and binge eating in college females concluded that dysfunction at the familial level leads to depressive symptoms and negative body image. Thus, dieting may be employed as a coping mechanism that predisposes one to additional eating problems such as binge eating.16 Including stress management techniques within weight management and eating disorder presentations may help educate college students on the important role stress plays in their eating behavior and body image. The increasing rates of both obesity and unhealthy eating behaviors among college students have led researchers to examine the psychosocial issues related to the weight management strategies among this population. A study conducted on weight loss practices and body weight perceptions among US college students, using data from the 2002–2003 NCHA, concluded that 12% of respondents had inaccurate body weight perception and that men and women with inaccurate body weight perception were significantly more likely to engage in inappropriate weight management strategies compared to respondents with accurate body weight perception.17 Furthermore, another study examined the relationship between eating disturbance, body image, and academic achievement and concluded that academic interference may be an outcome for individuals who experience eating problems and body image disturbance.18 Yet, little research exists investigating the relationship between inaccurate body weight perception, weight management strategies, and depressive symptoms. The purposes of this study were (1) to determine if inaccurate body weight perception predicts unhealthy weight management strategies in the 2006 NCHA reference group, and (2) to examine the extent to which inaccurate body weight perception may be associated with depressive symptoms. 44

METHODS Data were collected during the Spring 2006 semester using the NCHA. The NCHA is a survey instrument designed to collect information on a broad range of students’ health behaviors, health indicators, and perceptions. Of the 300 items in the NCHA, specific items of interest in this study include nutrition, weight management strategies, body image, body weight, impediments to academic performance, and feelings of depression and hopelessness. An interdisciplinary team of college health professionals developed the NCHA and pilottested it in 1998–1999 for reliability and validity.19 Construct and measurement validity analyses were conducted by comparing results of the ACHA-NCHA with nationally representative databases.19 We assessed reliability by comparing relevant percentages with nationally representative databases, and we assessed item reliability comparing overlapping items with a nationally representative database.19 One hundred twenty-three North American postsecondary institutions self-selected to participate in the Spring 2006 NCHA, resulting in 97,357 surveys. However, the NCHA Spring 2006 Reference Group included data from only those institutions that utilized random sampling techniques.13 The final sample consisted of 94,806 students on 117 campuses. The overall mean response rate was 35%. The response rate for schools administering paper surveys in randomly selected classrooms was 85.8% and 23.2% for schools conducting randomized Web-based surveying.13 Although institutions utilized random sampling techniques, the 35% response rate indicates that nonresponse bias is an inherent concern in this data set and it may not be representative of the general population. Data were cleaned for missing responses pertinent to the items used in our analyses. Only participants with calculated body mass index (BMI) data were included. We categorized participants as underweight (BMI < 18.5), normal weight (BMI = 18.5–24.9), and overweight (BMI ≥ 25). After these adjustments, 90,484 respondents were included in these findings. Participants provided demographic information such as age, sex, ethnicity, and relationship status. Participants also answered questions regarding height, weight, self-perception of weight, weight-loss goals, weight-loss strategies, health impediments to academic performance, and feelings of depression and hopelessness. Specifically, participants were asked: “How do you describe your weight?” (very underweight, slightly underweight, about the right weight, slightly overweight, very overweight); “Are you trying to do any of the following about your weight?” (I am not trying to do anything about my weight, stay the same weight, lose weight, gain weight); “Within the last 30 days, did you do any of the following?” (exercise to lose weight, diet to lose weight, vomit or take laxatives to lose weight, take diet pills to lose weight, I didn’t do any of the above); “Within the last school year, how many times have you felt?” (things were hopeless, overwhelmed by all you had to do, exhausted, very sad, so depressed it was difficult to function, seriously considered suicide, attempted suicide). For this study, vomiting, JOURNAL OF AMERICAN COLLEGE HEALTH

Body Weight, Weight Management, and Depressive Symptoms

use of laxatives, and use of diet pills are categorized as “unhealthy weight management strategies,” whereas dieting to lose weight and exercising to lose weight are categorized as “healthy weight management strategies,” although these can be abused. Self-reported height and weight were used to calculate BMI and categorize participants using National Institutes of Health (NIH) guidelines, despite limitations that pertain to self-report data that will be discussed. As demonstrated in a previous study, we categorized participants as having an “inflated” body weight perception if they perceived themselves to be overweight or very overweight when their BMI was either normal weight or underweight.17 Additionally, participants were categorized as having a “deflated” body weight perception if their BMI was overweight yet they perceived themselves as normal weight or under weight. Frequencies were tabulated for all demographic variables, BMI categories, body weight perceptions, weight management goals, weight management strategies, depressive symptoms, and impediments to academic performance. Binary logistic regression models were estimated to assess the extent to which inaccurate body weight perception was associated with weight management goals, unhealthy weight management strategies (vomiting, laxatives, diet pills), and depressive symptoms. Odds ratios for binary predictors were converted to approximate risk ratios following Zhang and Yu.20 Demographic characteristics such as age, sex, and race/ethnicity were controlled for in the regression models. All statistical analyses were conducted in SPSS version 14.0. Differences were considered significant at p = .05, and risk ratios were considered significantly different if 95% confidence intervals did not include 1. The University of South Carolina Institutional Review Board approved the study. RESULTS Among the sample respondents, 63.5% were female, 72.8% were white, and 53.4% were single. The mean age of the respondents was 22.3 years (SD = 5.6). Among male and female respondents, 36.2% perceived themselves to be overweight or obese (see Table 2), whereas 31.3% were actually overweight or obese according to their BMI category. In addition, 28% of all respondents suffered from an inaccurate body weight perception. Among these respondents, 46.2% perceived that they were in a higher BMI category (inflated body weight perception) and 53.8% perceived that they were in a lower BMI category (deflated body weight perception). Among respondents who suffered from an inflated body weight perception, 83% were female and 16.9% were male. Among respondents who suffered from a deflated body weight perception, 29.4% were female and 70% were male. Despite that only one-third of respondents were considered overweight or obese by their BMI category, 51.3% of respondents indicated that they were trying to lose weight. Among the respondents who indicated that they were trying to lose weight, only 45.5% were actually overweight. Although 55.8% of respondents exercised to lose weight and VOL 59, JULY/AUGUST 2010

35% dieted to lose weight, only 30% used a combined approach of diet and exercise in order to lose weight. Sex-specific results, presented in Table 1 indicated that 39.2% of males were classified as overweight, compared to 25.7% of females, a significant difference (χ 2[1, N = 88,587] = 1041.693, p < .0001). Additionally, 61.2% of females and 34.1% of males were currently trying to lose weight, which was significantly different (Z = −38.82; N = 90,397; 95% confidence interval [CI] = −.131 to −.119; p < .0001). Women were also significantly more likely to suffer from an inflated body weight perception than were men (Z = 46.61; N = 88,587; 95% CI = .105 to .113). Results from the binary logistic regression analyses for males and females with an inflated body weight perception are presented in Table 2. The results demonstrated that females with an inflated body weight perception were significantly more likely to engage in unhealthy weight management practices than were males with an inflated body weight perception. Males with an inflated body weight perception were no more likely to engage in unhealthy weight management practices than were males with an accurate body weight perception. Males with an inflated body weight perception were actually less likely to vomit to lose weight than were males with an accurate body weight perception. These results demonstrate that inaccurate body weight perception has a significant effect on the weight management practices among females, whereas it seems to exert no effect on the weight management practices among males. Among overweight females with an accurate body weight perception, binary logistic regression analyses indicated that overweight females were more than 21/2 times as likely to use diet pills to lose weight (RR = 2.74; 95% CI = 2.51–2.99; p < .0001). This relationship was also found to be significant among overweight males (RR = 1.46; 95% CI = 1.29–1.64; p < .0001). In addition, overweight males (RR = 1.31; 95% CI = 1.29–1.34; p < .001) and females (RR = 1.47; CI = 1.45–1.50; p < .0001) with an accurate body weight perception were more likely to lose weight by exercising. Interestingly, overweight females with a deflated body weight perception were 1.63 times more likely to use diet pills to lose weight than were normal weight females with an accurate body weight perception (RR = 1.63; 95% CI = 1.28–2.07; p < .0001). No significant relationship existed for overweight males with a deflated body weight perception. Significant relationships also existed for females and males regarding inaccurate body weight perception (inflated and deflated) and depression. Normal weight females with an inflated body weight perception were significantly more likely to report feeling depressed in the last year (RR = 1.29; 95% CI = 1.22–1.355; p < .0001). No significant relationship existed for males with an inflated body weight perception. However, overweight males with a deflated body weight perception were significantly less likely to report feeling depressed in the last year (RR = .72; 95% CI = .66–.78; p < .0001). This relationship did not exist for overweight females with a deflated body weight perception. Alternatively, overweight females with an accurate body weight 45

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TABLE 1. Percentage of Participants’ Body Mass Index (BMI), Body Weight Perception, Body Weight Distortion, Weight Management Goals, and Weight Management Strategies, by Sex Category BMI Underweight Normal weight Overweight/Obese Body weight self-perception Underweight About the right weight Slightly overweight Very overweight Body weight distortion Inflated Deflated Weight management goals Do nothing Lose weight Stay the same Gain weight Weight management strategies Exercise Diet Vomit Diet pills Diet and exercise

Total (N = 90,484)

Women (n = 57,456)

Men (n = 38,028)

4.5 64.2 31.3

5.6 67.6 26.7

2.6 58.2 39.2

10.5 53.1 32.5 3.9

7.5 53.1 34.8 4.6

15.6 53.2 28.4 2.8

12.9 13.7

16.8 6.3

5.9 26.7

17.1 51.3 24.3 7.2

13.4 61.2 23.4 2.0

23.7 34.1 26.0 16.2

55.7 34.9 2.5 3.6 30.0

62.7 42.4 3.6 4.6 36.4

43.7 22.1 0.7 1.9 19.0

Note. BMI categories: underweight < 18.5, normal weight 18.6–24.9, overweight/obese ≥ 25. Individuals were classified as suffering from an inflated body weight distortion when they perceived themselves to be overweight when they were normal weight or underweight on the basis of BMI. Individuals were classified as suffering from a deflated body weight distortion when they perceived themselves to be normal weight or underweight when they were overweight on the basis of BMI.

perception were more likely to report feeling depressed in the last year than were overweight males with an accurate body weight perception (RR = 1.45; 95% CI = 1.39–1.51; p < .0001).

less overweight than they actually were. This is consistent with findings from the Behavioral Risk Factor Surveillance System (BRFSS), which concluded that more women in the United States were dieting to lose weight than men, though men had higher average BMI than did women.21 Furthermore, this study supports the findings from a smaller study that concluded that the majority of college normal and overweight females (83%) reported that they have consciously tried to lose weight.22 It is evident that there is an ongoing weight concern among college females of both normal and overweight BMI categories, yet this concern is less apparent among overweight males and not at all apparent in normal weight males, which is consistent with previous research.17,21,22

COMMENT Our results further demonstrate the need to examine the role of body weight perception in the weight management strategies of college women. In this study, fewer females than males were considered overweight, yet significantly more females than males indicated that they were trying to lose weight. In addition, females were more likely to perceive themselves as being more overweight than they actually were, and males were more likely to perceive themselves as being

TABLE 2. Risk Ratios (RRs) for Involvement in Unhealthy Weight Management Practices Among Participants With an Inflated Body Weight Perception Women

46

Men

Category

OR

95% CI

OR

95% CI

Vomit to lose weight Diet pills to lose weight Exercise to lose weight

1.76 2.23 1.19

1.57–1.96 2.01–2.47 1.14–1.45

.45 ns ns

.31–.67 ns ns

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In this study, weight loss was important to participants, yet only 36.4% of females and 19% of males were using a combined strategy of diet and exercise to lose weight. This is an important implication for college wellness programming because the Dietary Guidelines specifically emphasize that combined physical activity and healthy eating are recommended for weight management.23 A lack of awareness among college students of the efficacy of employing both changes in diet and physical activity may be a reason why the 2 strategies were not reported together among the majority. In addition, some college students may find changes to their diet hard to implement, whereas other students may find increasing physical activity to be a real challenge. Colleges should promote the Dietary Guidelines as a resource for students who want to lose weight.23 Independent meal planning is a challenge with which young adults are faced in college, and eating habits formed in college often continue into adulthood. Another factor that may influence an individual’s decision to engage in weight control behavior is normative beliefs. Clemens et al found that normative beliefs appeared to be a large determinant of an individual’s weight management strategy.24 For example, among both sexes, perceptions of same-sex, close friends’ weight-control practices were the single best discriminators of the low- and high-involvement weight-control groups. Therefore, these findings suggest that close friends may have an influence on weight control behavior.24 Thus, an effective strategy for college health professionals to diversify their weight management programming may be to openly communicate with students in their peer groups (eg, residence halls, Greek organizations, sports teams, etc) about healthy and unhealthy dieting practices. Through this targeted communication, students can learn appropriate weight management strategies and also become aware of the health consequences associated with unhealthy dieting behaviors. Findings from this study support the findings of a previous study that found dieting by college females is a common weight management strategy, irrespective of weight status.22 Additionally, Malinauskas et al found that females perceive healthy and attractive weights to be lower than current weight, and that media influence contributes pressure to be a certain weight.22 Furthermore, a related study reported that female dieters had low body satisfaction and suggested that to improve health, it is important to address body image dissatisfaction with chronic dieting, despite the weight status of the dieter.25 Our findings were consistent with previous research, in that we found that normal weight females with an inflated body weight perception were much more likely to engage in unhealthy weight management strategies such as vomiting and taking diet pills to lose weight. Moreover, overweight females who had an accurate body weight perception were almost 3 times as likely to use diet pills to lose weight than their normal-weight counterparts. Even overweight females who perceived themselves to be of normal weight were more likely to use diet pills to lose weight. No such relationships existed for males. These findings have pertinent implications for college health professionals. Weight VOL 59, JULY/AUGUST 2010

management programs for the college population must emphasize body image issues and the extent to which they are predictive of unhealthy weight management practices. Targeted messages and programs must promote regular exercise and healthy eating, but also focus on body image and body satisfaction, while being sensitive to the extent to which inaccurate body weight perception predisposes females to unhealthy weight management strategies and possibly eating disorders. It has been established in the literature that exercise behavior is associated with increased depression and anxiety among women with eating disorder symptoms.26 A previous study that examined the relationship among exercise, disordered eating, and psychological health among college students found that among women with high Eating Attitudes Test (EAT-26) scores, exercise had a negative effect and was associated with higher levels of depression and anxiety.27 Exercise did not produce this negative effect among women who had low EAT scores.27 Although this present study did not examine the effect exercise had on depression and anxiety, we did investigate the association between inaccurate body weight perception and depressive symptoms. Our findings support previous research such that normal weight females with an inflated body weight perception were significantly more likely to report feeling depressed in the last year, as were overweight females with an accurate body weight perception. These conclusions are critical in the college health programming for females in that college health professionals need to be aware that exercise can be a negative adaptive behavior for females suffering from eating disorder symptoms and more attention may need to be placed on addressing body image issues and eating disorders before recommending formal exercise programs. Introducing activities designed to promote mind and body awareness, such as yoga and tai chi, may be a therapeutic alternative to more vigorous activities that focus on burning calories. A related area that has received limited attention is the role that body image disturbances might play in interfering with optimal cognitive performance. Wardle et al concluded that restrained eaters tended to eat more calories, fat, and sugar when exposed to work stress and stress from social situations.14 Furthermore, Yanover and Thompson examined the relationship between eating disturbance, body image, academic achievement among a large sample of college undergraduates and concluded that higher levels of eating disturbance and body dissatisfaction were associated with higher levels of interference in academic achievement.18 Our results support these findings, that normal weight females with an inflated body weight perception were significantly more likely to report that stress impacted their academic performance. This relationship was only observed among females with an inflated body weight perception and not among any other group. This is important for college administrators because of the established link between health and retention.28 Efforts need to be focused on students’ emotional health and on addressing the stressors our students are facing in order to promote optimal academic performance. 47

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Limitations Several limitations to this research should be noted. First, the cross-sectional data collection precludes causal interpretations of the findings, though patterns of association may be observed. Second, the generalizability is limited because universities self-selected to participate in this study, although participants were selected at random. Moreover, it must be pointed out that the study response rate of the NCHA in 2006 was 35% and thus nonresponse bias is an inherent concern. Although the Web survey response rate was lower than the paper and pencil survey, the ACHA has examined the difference between the 2 survey types and found negligible differences.29 Specifically, the students who responded online tended to live on campus and were slightly younger than those who used paper surveys.30 Additionally, institutions that were not members of the ACHA were charged an additional fee to participate in the NCHA and this may represent another source of bias. However, results gathered in this study were consistent with previously gathered, national data.11 Finally, data were self-reported, which introduces additional biases to the findings. Survey items were not extensive enough to define what is considered “dieting” or differentiate between various kinds of “diet pills.” Malinauskas et al concluded that dieting strategies have become so “main stream” in our society, that one may not be aware of the behaviors that are being used to consciously lose or control one’s weight.22 Therefore, participants in our study were forced to utilize their own definition of dieting, which may have biased our findings. Additionally, the use of BMI may be a limitation because it does not account for body composition. There is the potential that some of our participants were classified as “overweight” based on their self-reported weight and height, yet would not be clinically considered “overweight” as a result of their muscle mass. For instance, this occurrence likely skewed the proportionally large number of males who were identified as having a deflated body image and thus explains the weak associations between males with a deflated body image and the outcome variables. On the contrary, overweight college females tend to underestimate their self-reported weight and height and this could negatively impact overall prevalence rates in the study.31 Despite these discrepancies, overall, BMI is a population-based measure that has been found in clinical settings to be a good approximation for assessment of total body fat for a majority of patients.31a,31b Although a major strength of this study is the large sample size, it is important to distinguish between clinically significant and statistically significant results. With a sample size of more than 90,000 respondents, we were careful to report only the practically meaningful findings. Additionally, the NCHA has been extensively validated by a panel of health experts.13,19 Furthermore, although universities self-selected to participate, only universities who used random selection of participants were included in this sample.

management strategies, and psychological distress. There is an absence in the literature on the weight management programming needs of college males, yet this study shows that college males could use health programming designed to educate them on what is a healthy weight and appropriate strategies for nutritious eating and adequate physical activity. College males share issues related to weight concern with their female counterparts. A study found that overweight and obese college men have body dissatisfaction. In the same study, underweight college males were concerned about losing muscle mass.32 Body image issues related to weight management strategies in males and females still exist and more evidence-based interventions need to be developed to address the extent to which body image perceptions have a negative impact on health. Future programming should address health concerns related to both those students who are trying to lose weight, as well as those who are trying to gain muscle. Both groups need to focus on achieving their goals in a healthful manner that includes both diet and physical activity. In terms of future research and programming, studies could examine the differences among female college students by ethnicity or race using focus groups to identify more specific differences regarding weight, body image, and body weight perception. In addition, focus groups may present an opportunity to discern what impact concerns about weight have on socioemotional health, in a more detailed manner than can be provided via a survey. Recent research regarding differences in body dissatisfaction by race/ethnicity among women is very inconsistent,35–42 future research among college students could add an important perspective. Additionally, future research should focus on the relationship between body image, stress, and academic achievement. Developing theory-based interventions that include more holistic approaches to well-being may be effective in addressing some of the psychosocial effects resulting from an inaccurate body weight perception. On the basis of these findings, we suggest that college health professionals continue their work on body image and weight management programming43–45 while incorporating both exercise and nutrition components. In addition, future research is needed to elucidate how complimentary programming, such as biofeedback and self-hypnosis, may be integrated into more traditional efforts to help college students address body image concerns and help them to identify ways in which they can improve self-image and engage in healthy weight management strategies. Implementing theory-based interventions that incorporate complimentary programming along with practical determinants of healthy weight loss, such as knowledge of the preparation and selection of healthy foods, social support of friends and peer groups, and improved self-efficacy for engaging in physical activity, may help students to maintain a healthy weight and appropriate body image.

Conclusions Despite limitations of this study, the findings shed light on the relationship between body weight perception, weight

NOTE For comments and further information, address correspondence to Holly Anne Harring, MSPH, Department of Health

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