Body Mass Index and Body Weight Perception as Risk Factors forInternalizing and Externalizing Problem Behavior Among Adolescents
Tom F.M. ter Bogt, Ph.D.a,*, Saskia A.F.M. van Dorsselaer, M.A.a,Karin Monshouwer, M.A.a, Jacqueline E.E. Verdurmen, Ph.D.a,
Rutger C.M.E. Engels, Ph.D.b, and Wilma A.M. Vollebergh, Ph.D.aaTrimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
bRadbout University, Nijmegen, The Netherlands
Manuscript received March 21, 2005; manuscript accepted September 20, 2005
eywords: Body mass index; Body image; Adolescents; Problem behavior; Internalizing problem behavior; Externalizing
Journal of Adolescent Health 39 (2006) 27–34
problem behavior; Youth Self-Report
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A major task in adolescence is getting comfortable withbody that is changing rapidly over the course of a rela-
ively short time span [1]. Research has documented that
*Address correspondence to: Dr. Tom ter Bogt, Trimbos Institute,etherlands Institute of Mental Health and Addiction, P.O. Box 725, 3500S Utrecht, The Netherlands.
his developmental task affects young people in differentays. Failure to adapt to new bodily features and dissatis-
action with body image may be indicators of or factors inhe development of psychopathology [2,3]. The goal of thistudy is to examine the concurrent association of an indi-ator of weight, i.e., body mass index (BMI), and bodyeight perception (BWP) with a range of internalizing and
xternalizing problem behaviors.
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In industrialized countries, high-fat foods, carbohydratesnd sugar are available relatively inexpensively, and youngeople have increased their consumption of these high-alorie foods [4,5]. They also tend to watch more television,nd their physical activity is insufficient to counterbalancehe effects of eating and drinking more and sitting longer inront of the TV [6]. Obesity is a cultural trend and someuthors have even called the rapid increase in the number ofverweight and obese (young) people an epidemic [7].
A lean body image has remained the dominant ideal foroth men and women throughout Western countries. Theedia, parents, siblings, peers and partners may all con-
ciously or guardedly criticize adolescents for being ‘tooat’ and consequently less attractive [8]. As an increasingroportion of the adolescent population faces obesity, theultural ideal of thinness is even harder to achieve now thant has been in recent decades [9 –11]. One of the mostersistent outcomes of research on body image satisfactions that preadolescent and adolescent girls and young womenre more dissatisfied with their bodies than their male peers.
omen are more inclined to compare themselves with cul-urally dominant body image ideals that glamorize thin,dolescent features and because the idealized weight iselow average for their age and gender, the comparisonends to be to their disadvantage [12–18].
Whereas females are generally anxious about being over-eight and diet more often, body dissatisfaction for males
an go two ways. Research has shown that men either abover below the medium range of BMI scores for their age tendo be dissatisfied with their body image [18]. In contrast toemales, being too thin can be as serious a problem forales as being overweight. They might compare themselvesith a cultural ideal in which muscularity exceeds the av-
rage [4].Among adolescents, higher BMI is associated with
reater body image dissatisfaction [19,20], and both BMInd several subjective indicators of weight and appear-nce—‘weight concerns’, ‘body image satisfaction’, ‘bodysteem’, ‘negative body image integration’, ‘body uninte-ration’—have been linked to psychopathology. Over-eight adolescents are socially marginalized [21]. Body
mage dissatisfaction has been related to frequent dietingnd is considered a major factor in the etiology of eatingisorders across ethnic groups [22], especially for (adoles-ent) females [2,8,15]. McClintock [23] found correlationsetween body esteem, social support, and several forms ofsychopathology, including social phobia. A link has beenstablished between body image dissatisfaction and depres-ion [24,25], anxiety [26,27] and negative emotionality28]. More specifically, Roth [3] has reported that of threeypes of young people characterized as ‘body uninterested’,body active’, and ‘body unintegrated’, the latter groupcored highest on a general indicator of psychopathologynd in particular showed higher scores on internalizing
roblems, i.e., depression, anxiety and attention deficit. e
ody image dissatisfaction has also been related to exter-alizing problem behavior. For instance, Jurich and An-rews [29] found juvenile delinquents to be more dissatis-ed than their non-delinquent peers.
Research on body mass and body image strongly focusesn dieting, eating, eating disorders and symptoms of depres-ion, especially among women [30]. In a review of twoecades of research, Stice and Shaw [8] suggest that bodyass is a risk factor for body dissatisfaction that in turnediates dieting and negative affects, both solid predictors
f eating disorders. Although the body image–eating disor-ers link is a vastly important topic for study and there haseen an ‘explosion’ of body image research over the pastwo decades, empirical findings on the relationship betweenody mass and body image satisfaction as predictors ofxternalizing problem behavior are scarce and little isnown about the relationship between body mass and bodymage, on the one hand, and externalizing problem behaviornd social, thought and attention problems, on the other. Inddition, most studies on body image problems have smallamples and, more specifically, epidemiological data is un-vailable for adolescent boys [31].
In this study, we examine the concurrent relationshipetween adolescent body mass index (BMI) and bodyeight perception (BWP) with indicators of internalizing
nd externalizing distress and social, attention, and thoughtroblems in a large, representative sample of Dutch childrennd adolescents. Problem behaviors are known to be asso-iated with age, family affluence, and the quality of rela-ionships with parents and peers [32]. For these reasons, weontrolled for several background variables—Gender, Age,ousehold Composition, Family Affluence and Social Sup-ort from Parents and from Peers.
ethod
ample
A sample of 1826 pupils in the eighth grade of primaryducation and 5730 pupils in the first four years of second-ry education (a total of 7556 students) completed the ques-ionnaires. This sample from the Health Behavior in School-ged Children (HBSC) study is representative for the Dutchopulation of school children aged 11–16 years. Detailedescriptions of the sampling procedure can be found in [33].
ata collection
All data were collected with questionnaires, which wereistributed in classes and administered by teachers (by aesearch assistant at four schools) during class (usually 50inutes). Teachers emphasized the anonymity of respon-
ents when introducing the questionnaire. Anonymity wasurther guaranteed by collecting all questionnaires in one
nvelope and sealing it in the presence of the respondents.
29T.F.M. ter Bogt et al. / Journal of Adolescent Health 39 (2006) 27–34
easures
Sociodemographic measures included Age (in years),ender (female, male), Household Composition (‘not livingith both biological parents,’ ‘living with both biologicalarents’) and Family Affluence (low, medium, high). Fam-ly Affluence was assessed with four questions connectedith the presence of material items in the family: number of
ars, student having a bedroom of his/her own, number ofomputers, and number of times each year the family goesn holiday. Together, these items can be interpreted as anndicator of family prosperity. In accordance with the HBSCrotocol, the answers were recoded into the aforementionedhree categories. Social support provided by father/mother/riends (good, poor, no contact) was assessed using items ofhe core HBSC questionnaire [33].
ody mass index. Students were asked to give their heightnd weight. A BMI score was calculated on the basis ofhese self-reported estimates. It has been shown that thisype of calculation results in a reasonable assessment ofMI [34]. Overweight/obesity and underweight criteriaere derived from accepted Dutch Quotelet standards [35].
ody weight perception. Body weight perception was as-essed with one item, the following question: ‘What do youhink of your own body? Is it . . .’ Answer categories on ave-point Likert scale ranged from ‘far too thin’ to ‘far tooeavy’. ‘Far too thin’ and ‘too thin’ were compressed intone category, as were ‘far too heavy’ and ‘too heavy’.
orrespondence of BMI and BWP. Adolescents with BMInd BWP scores on a corresponding level—underweight–far) too thin, normal–good, overweight–(far) too heavy—ere categorized as having an adequate view of theireight, whereas the others were believed to either under-
stimate or overestimate their weight.Internalizing and externalizing problems were measured
ith the Youth Self-Report (YSR) [36], which is designedo be completed by 11–18-year-old adolescents. Items onifferent kinds of problems are scored as follows: 0 �ntrue, 1 � somewhat true, 2 � very true or often true, onhe basis of prevalence in the preceding six months. TheSR can be scored on the sum of all problem scores and the
ollowing five subscales: Anxious/Depressed, Withdrawnnd Somatic Complaints (Internalizing Problems); Aggres-ive Behavior and Delinquency (Externalizing Problems);ocial problems; Thought problems; and Attention prob-
ems (which are not part of either the internalizing or ex-ernalizing scale). Achenbach has documented the reliabil-ty and validity of the YSR (1991) [36]. The questionnaireas translated and validated for use in the Netherlands byerhulst et al [37].
ata analysis
There are two characteristics of the data that must be
aken into account in the analysis. Firstly, students from the a
ame class were drawn as a cluster. A cluster sample willot affect point estimates, such as prevalence rates andazard rates, but it will affect variance-related estimates,uch as sample errors, 95% confidence intervals (95% CIs)nd p values. Secondly, the sample had to be weighted tobtain correct 95% CIs and p values under weighting and inclustered sample, robust standard errors were obtainedith the first-order Taylor-series linearization method. Mul-
ivariate linear regression analyses were carried out to ex-mine the association between BMI, BWP, and problemehavior, resulting in standardized regression weights (�s).
We performed three types of analyses. In the first round,MI and BWP were separately associated with problemehavior, controlling for the effect of confounding vari-bles: Gender, Age, Family Affluence, Household Compo-ition, and Support from Parents and Peers. In the secondodel, we introduced both BMI and BWP in the analysis to
stimate their relative importance problem behavior. Next,ifferent combinations of BMI and BWP were tested inrder to examine which composite showed the strongestssociation with problem behavior. All analyses were car-ied out with Stata (version 7.0; Stata Inc., College Station,X).
esults
escriptive results
Table 1 shows BMI and BWP scores and the correspon-ence between these two scores by Gender and Age. In the1–16-year-old age category, 5.8% of both Dutch boys andirls are underweight, whereas 10.1% of the boys and 8.3%f the girls are overweight. During adolescence, the per-entage of both underweight boys and girls decreases frompproximately 6% at age 11 to 4.5% and 3.4%, respectively,t age 16. The proportion of overweight girls drops in earlydolescence from 10.2% to around 6.4%, then stabilizes atpproximately 9%. This proportion increases from 7.8% to3.3% for boys (Table 1).
Although approximately 85% of the whole group ofdolescents fall within the BMI normal weight range, theercentage of young people considering their weight ‘good’s considerably lower. Only 56% of the boys are satisfiedith their weight and this is even lower for girls; 44.3%.he percentage of young people, either boys or girls, satis-ed with their weight declines during adolescence, but girlshow a greater decrease than boys, i.e., from 53.1% to4.0% and from 59.3% to 52.4%, respectively. Girls andoys also differ conspicuously in experience of their weight:irls readily consider themselves too fat, whereas boys areore likely to consider themselves too thin. During adoles-
ence the percentage of girls perceiving themselves as tooeavy increases from 34.2% to 55.5%. The percentage ofoys considering themselves too thin increases from 15.4%
30 T.F.M. ter Bogt et al. / Journal of Adolescent Health 39 (2006) 27–34
Correspondingly, boys and girls differ systematically inhe way they underestimate and overestimate their weight.t age 16, 27.3% of boys underestimate their own weight
nd 15.4% overestimate it, whereas in the same age cate-ory, only 9.8% of the girls underestimate their weight and7.9% overestimate it. Around 60% of all adolescent boysave an adequate perception of their own weight and theame is true for about 50% of the girls. These young peoplehink they are too heavy when they indeed fall within theMI overweight category, experience their weight as goodhen they have normal BMI, and consider themselves too
hin when they are underweight. The proportion of boysith an adequate self-understanding decreases from around5% to 57%. This drop is far steeper for girls, from approx-mately 60% to approximately 42%. Thus, although a rela-ively large minority of all adolescents do not perceive theireight in accordance with their BMI, girls are even morerone to misperception of their weight than boys.
The upper half of Table 2 shows the results of separateultiple regression analyses of emotional and behavioral
roblems on dummy variables for BMI and BWP, respec-ively. Relevant control variables—Gender, Age, FAS,amily Composition, Peer and Parent Support–were in-luded in the analyses as potential confounders. Because ofarge group size, only significant associations with p � .01re reported.
Both diverging from normal BMI and body weight dis-atisfaction are significantly related to indicators of emo-ional or behavioral problems. In Model 1 with BMI statusess predictors, the BMI underweight category has significantut weak positive relations to anxiety/depression (internal-zing problems) (� � .04, p � .01) and social problems (�
.07, p � .01). BMI overweight category has more sig-ificant, although equally weak links (�s between .04 and
08, p � .01) with problem behavior in general, the totalnternalizing and externalizing problem scores and with-rawnness, anxiousness/depression, aggression, social
able 1ody mass index, body weight satisfaction and correspondence of BMI a
The results of Model 2 with BWP statuses as predictorshow that young people who consider themselves too thinenerally report more problem behavior, more internalizingistress, and score higher on all subscales, except delinquentehavior (�s between .04 and .08, p � .01). The linketween BWP too heavy and problem behavior is relativelytrong (�s between .07 and .18, p � .01), i.e., adolescentsndicating that they think they are too fat consistently showore problem behavior in a wide range of fields than peersho are satisfied with their weight. Perceiving oneself as
oo heavy linked to all of the internalizing and external-zing problems and social, thought, and attention problemsTable 2).
Model 3 included both BMI and BWP statuses as pre-ictors and �s indicate the concurrent relationship of BMInd BWP with the problem scores. In this model, under-eight BMI is still positively associated with anxiety/de-ression and social problems only (�s �.04 and .06, respec-ively, p � .01). Overweight BMI remains only significantlyinked to withdrawnness (� � .06, p � .01). None of theelationships between BMI statuses and externalizing prob-ems—total scale or subscales—are any longer significant.
On the whole, the BWP statuses of perceiving oneself asoo thin or too fat are more closely associated with problemshan deviating from BMI normalcy. Perceiving oneself asoo thin is related to higher scores on all problem behaviorscales except the externalizing scores, (�s between .04 and08, p � .01) and evaluating oneself as too heavy is linkedo all problem scores in this analysis (�s between .06 and18, p � .01). Together these results indicate that the mostubstantial relations were found between perceiving oneselfs too heavy and problem behavior. Furthermore, in the fullodel, BWP as a factor suppresses the BMI associations,
ndicating that BWP partly functions as a mediator betweenMI and problem behavior (Table 2).
We also checked for potential interactions of Gender,MI and BWP on problem behavior, but found only one
Model 4: full modelRef: BMI/BWP ‘normal/good’)Underweight/(far) too thin .04* .04* .03 .05* .01 .00 �.01 .01 .08* .01 .06*Underweight/good .03 .02 .02 .02 .00 .02 .02 .02 .03 .02 .01Normal/(far) too thin .06* .05* .04* .06* .03* .04* .02 .04* .06* .04* .06*Normal/(far) too heavy .16* .14* .07* .12* .14* .12* .09* .11* .08* .06* .10*(Far) too heavy/good .02 .02 .03 .01 .01 .01 .01 .01 .01 .01 .00(Far) too heavy/too heavy .13* .10* .09* .11* .04* .08* .05* .08* .09* .05* .05*R2 full model .16 .18 .14 .15 .10 .11 .13 .09 .07 .07 .11
* p � .01.Adjusted for: age, gender, FAS, living with both parents, quality relationship with parents and peers.Note: Standardized parameters are the final step of the equation.
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32 T.F.M. ter Bogt et al. / Journal of Adolescent Health 39 (2006) 27–34
eport fewer social problems than boys with the same self-erception. In sum, this indicates that boys and girls mayiffer in the way they evaluate their weight, but that asso-iations between BMI, BWP and distress are, on the whole,f the same magnitude.
Subsequently, Model 4 regarded an analysis with sevenout of nine possible) different combinations of weight andeight perception predicting problem behaviors while con-
rolling for confounders: BMI normal/perception normaleight [reference]; BMI underweight/perception too thin;MI underweight/perception normal; BMI normal/percep-
ion too thin; BMI normal/perception too heavy; BMI over-eight/perception normal; BMI overweight/perception tooeavy. Results revealed that both the groups that were eithernderweight or overweight, but evaluated their weight asood, had no more problems than the reference group ofoung people who had normal weight and felt good about it,hus stressing the importance of body perception (Table 2).pecifically, both groups that were either normal weight orverweight, and considered themselves overweight hadore problems than the reference group, indicating onceore that the perception of being overweight is the most
ubstantial predictor of a wide range of problems. In andditional analysis with the group that had an adequatenderstanding of its overweight (BMI overweight/percep-ion too heavy) as a reference category, we tried to specifyifferences between these last two groups. The resultshowed that on seven of our 11 outcomes, the normaleight/perception overweight group did not show moreroblems than the group with an adequate understanding ofts overweight. However, young people with normal weightearing they are overweight did have more somatic com-laints than the overweight group, whereas this last grouphowed elevated levels of withdrawn behavior, social prob-ems, and anxiety/depression (all p � .05). In sum: theerception of being overweight is a strong predictor ofroblem behavior, both for normal weight and overweightoung people, but the problems faced by the first groupiffer to some extent from the ones the other group encoun-ers. Comparing these two groups, youngsters evaluatinghemselves as too heavy while having normal weight tendedo have more somatic complaints; their truly overweighteers making the same evaluation reported more problemsith social interaction and heightened anxiety/depression.
iscussion
Havighurst [1] classified the acquisition of a positiveody image as one of the central developmental tasks ofdolescence. In a cultural climate fostering both obesityith the availability of an abundance of high-calorie food
nd ideals of leanness and muscularity supported by mediaoverage of high-status role models, increasing numbers ofdolescents are confronted with demands on their body
hape that are hard to meet.
We studied a large, representative sample of Dutchoung people, aged 11–16 years, and found that boys mayompare themselves to the ideal of a lean, muscular bodyype, prompting the anxiety of being either too skinny or tooat, even when their weight is in the normal BMI range, andirls may have ideals of impeccable thinness, evoking fearsf irreversible fatness when their BMI is healthy. Duringate adolescence, body weight dissatisfaction applies tobout half of the boys and a majority of the girls, indicatinghat adolescence is indeed a period of intensified worrybout the shape and size the body will take in adulthood.ur results confirm findings from studies in other coun-
ries—Australia, UK, USA—indicating that the same set ofender-specific cultural pressures on ideal body shape op-rates throughout the industrialized world [12–14].
Cultural factors are important in the development ofsychological distress [22,30,38]. Although populationsay differ in terms of thinness or chubbiness, being over-eight is primarily linked to lower self-esteem and problemehavior when the weight level and accompanying bodyhape is culturally categorized as ‘unaesthetic’ or ‘ugly’38]. It is therefore plausible that culturally mediated bodyeight dissatisfaction is a better predictor of problems thaneight and BMI per se [30]. Our results support this as-
umption.Deviance from normal weight is associated with inter-
alizing distress, but not with externalizing problems.ower BMI scores relate to greater problems, more specif-
cally to anxiety/depression and social problems, higherMI is associated with withdrawnness. However, BWP is aore substantial predictor of adolescent distress. Both boys
nd girls experiencing their body as too thin or heavy findhemselves in an unfavorable position, across age groupsnd socioeconomic position. Subjects categorizing them-elves as too thin or too fat exhibit elevated levels ofnternalizing, externalizing, social, thought and attentionroblems, with associations being strongest for the evalua-ion of one’s weight as too heavy. Perception of being tooeavy is the most substantial predictor of a wide range ofroblems and both the overweight and the young peopleith normal BMI are affected.Thus, consistent with previous research, we found both
MI and even more so BWP to be associated with inter-alizing problems [3,25–28]. Furthermore, our findings sup-ort limited previous research on the link between bodymage and externalizing distress [29]. We also found a linketween weight perception and social, thought and attentionroblems, one more sign that weight dissatisfaction indi-ates a wide range of problems. An intriguing result is that,lthough body image is a highly gendered phenomenon,inks between BMI, BWP, and distress are on the wholeimilar for boys and girls. Perceived deviance from theulturally specific ‘normal’ body weight results in a height-ned risk of psychosocial problems for both genders.
The link between BWP and externalizing distress should
33T.F.M. ter Bogt et al. / Journal of Adolescent Health 39 (2006) 27–34
e the object of more theoretical speculation. Furthermore,lthough a vast body of work conceptualizes the associationetween high BMI and feelings of being too fat and problemehavior, relatively little attention has been focused on theink between feelings of thinness and problem behavior,lthough perceptions of thinness may be a factor that to aertain extent contributes to psychosocial distress for bothoys and girls. Last but not least, the developmental path tonternalizing and externalizing distress and other problemsonsists of a complex interplay of actual body size, cultur-lly mediated interpretations of body size, and individualifferences in personality. Although cultural factors seem toe partly responsible for feelings of body dissatisfaction thatre common throughout large parts of the adolescent pop-lation, our results indicate a need for studies that clarifyhich girls and boys are particularly at risk for negatively
nterpreting their body size and, consequently, for problems.A limitation of this study is that subjective indications
f weight and height were used to obtain a BMI score.lthough some authors have suggested that this could
ead to a fairly good BMI rating [34], conservative in theense that it slightly underestimates the proportion ofverweight people, others have questioned the reliabilityf this procedure [39]. Due to large sample size, it wasmpossible for us to precisely measure weight and height.urthermore, we used a general measure of body weightatisfaction, assessed with a single item. Although thisuestion may assess overall (dis)satisfaction with bodyeight, it is not specific enough to evaluate different
spects of weight or image concerns and their link toroblem behavior. In other words, using more sophisti-ated measures would make possible a more detailedodeling of the relationship between weight/image con-
erns and problem behavior relationship. Next, our cross-ectional study design allowed us to report only on con-urrent BMI and BWP associations with outcomes.lthough we found further evidence for weight percep-
ion mediating the link between weight and problems, weere unable to model longitudinally or assess causality in
hese associations. This is an important issue when study-ng the link between adolescent weight, weight concerns,nd distress. Insight into causal mechanisms and thetiology of adolescent problem behavior related to bodyeight and body image is not only important for a the-retical understanding of distress, but also crucial foresigning effective interventions at the personal, socialnd cultural levels.
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