Issues of Self-image among Overweight African-American and Caucasian Adolescent Girls: A Qualitative Study

Issues o f Self-Image among Overweight African-American and Caucasian Adolescent Girls: A Qualitative Study D I A N N EN E U M A R K - S Z T A I N E RMARY ,' STORY,' L O R E N F A I B I S C H J, I~L L O H L S O N , ' AND MICHELLE ADAMIAK~ 'Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis, Minnesota 55454; 2Mary E. Switzer Rehabilitation Fellow, University of Minnesota, Minneapolis, Minnesota 55454; 3Maternal and Child Health Unit, School of Public Health, University of Minnesota, Minneapolis, Minnesota 55454

ABSTRACT This study aimed to gather in-depth descriptions of the experiences of overweight adolescent girls to understand how they view themselves and their social context. The study further aimed to compare body and self-image issues among African-American and Caucasian overweight girls. The study population included 50 adolescent girls, aged 14 to 20 years, from junior and senior urban public high schools in St. Paul, MN. Individual interviews, using a semistructured interview guide, were used to gather rich descriptions of experiences. Interviews were taped, transcribed, and coded. Weight issues were central to the manner in which the girls described themselves and their ideal selves.They discussed people-related and clothing-related situations in which they felt self-conscious due to being overweight.Yet, being overweight was clearly not the only aspect of their lives, and they expressed concerns common to many adolescents. Both similarities and differences in attitudes were identified when the African-American and Caucasian girls were compared. African-American and Caucasian girls indicated their desire to be thinner, expressed dissatisfaction with their body shape and body size, and discussed situations in which they felt self-conscious due to their weight. However, the African-American girls were more likely to also discuss the positive aspects of their bodies than the Caucasian girls. Furthermore, specific situations in which the girls felt selfconscious tended to differ across ethnicity. Health care providers need to take the time to discuss both weight-related and nonweight-related concerns of overweight youth in counseling situations and ask about issues of self-image and social interactions in an empathetic manner. Furthermore, since many of the negative statements made by the girls focused on interactions with others, health care providers and educators may want to consider strategies for reaching peers, family members, and others with messages about their potential influence on the overweight adolescent's development. Implications for research on the psy-

................................................... This study was made possible through grants fromThe American Heart Association, The Minnesota Obesity Research Center, and The University of Minnesota. Address for correspondence: D ~ a n n eNeumark-Sztainer, Ph.D., M.P.H., R.D., Division of Epidemiology, School of Public Health, University of Minnesota, 1300 South Second Street, Suite 300, Minneapolis, M N 55454;Tel: (612) 624-0880; Fax: (612) 624-0315. 01999 SOCIETY F O R NUTRITION EDUCATION

chosocial consequences of obesity include assessing domainspecific aspects of self-image.

INTRODUCTION We live in a society in which thinness is valued and overweight individuals are stigmatized in many areas of their lives.'-6 While it is widely assumed that overweight adolescent girls have increased psychosocial concerns, such as lower self-esteem, body dissatisfaction,and peer concerns, than their nonoverweight peers, results from numerous studies have revealed inconsistent finding^.^-^.' In a comprehensive review of the literature in this area, consistent associations were not found between self-esteem and obesity, but were found . ~ lack of conbetween body dissatisfaction and o b e ~ i t yThe sistency in associations between obesity and self-esteem suggests that the association is weaker than commonly believed. Additionally, the lack of consistency may be a reflection of the differences in measures used to assess self-esteem, populations included in the various studies, or other aspects of study methodology. We examined associations between weight status and psychosocial concerns using data collected with the Minnesota Adolescent Health Survey (MAHS) on a statewide sample of over 30,000 adolescent girls and boys in grades 7 to 12.9The sample was approximately 86% Caucasian, 8% AfricanAmerican, 1%Hispanic, 2% American Indian, and 3%Asian American; this closely resembles the student population in Minnesota.We found that overweight youth were more likely to report weight-specific concerns and behaviors such as weight dissatisfaction, binge eating, and frequent dieting than nonoverweight youth. However, only small differences were noted between overweight and nonoverweight youth with regard to global psychosocial concerns such as emotional well-being, suicidal ideation, future job concerns, and peer concerns. One explanation for these findings is that overweight and nonovenveight youth did not differ from each

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other with regard to global psychosocial concerns.An alternate explanation is that survey questions were not sensitive enough to detect subtle differences between the overweight and nonoverweight youth since the MAHS was designed to examine a range of health-related topics; thus, the items assessing specific psychosocial concerns were relatively brief. We proposed that a study employing qualitative research methodologies, aimed at gathering rich and in-depth contextual information on the personal and social experiences of overweight youth, would enable the examination of issues of self-image from a different perspective and would complement previous quantitative studies. More specifically, we thought a qualitative study focusing on issues of self-image among overweight girls might (1) lead to a greater understanding of issues of self-image among this population, (2) inform educational and treatment approaches, and (3) facilitate the development of more sensitive survey instruments. Findings from qualitative research, in particular when complemented by quantitative findings, have the capacity to greatly enhance our understanding of complex issues.'@15 Thus, the first aim of this study was to gather in-depth descriptions of experiences related to body and self-image from overweight adolescent girls in order to better understand how they view themselves and how they relate to their social context given that they are overweight. Ethnic differences in prevalence rates of obesity among youth have been documented, with particular attention given to the high prevalence rates among African-American girls. While obesity is prevalent among Caucasian adolescent girls (22%), its prevalence rates are considerably higher among African-American adolescent girls (30%).16Factors that have been proposed as contributing to this disparity include differences in cultural and social norms influencing body and self-image.",'* In their review of the literature on self-esteem and obesity, French et al. concluded that few data were available to permit evaluation of the moderating effect of race/ethnicity and that future studies are needed in this area.* They further suggested that "...because the black culture is thought to be more tolerant of obesity, overweight black adolescent females may be protected against low selfesteem or body-esteem" (p. 488).* Desmond et al. studied a school-based population of adolescents and found that African-American girls were less likely to perceive themselves as heavy and expressed more satisfaction with their appearance than Caucasian girls.19 Parker et al. found African-American girls to be more flexible than Caucasian girls in their concepts of beauty; they spoke of "making what you've got work for you" (p. 11 In contrast, they reported that many of the Caucasian girls expressed body dissatisfaction and were rigid in their concepts of beauty.20However, in both of these studies, the numbers of overweight youth were small. Fewer studies have focused on comparing the self-perceptions of overweight African-American and Caucasian youth. In our previously cited study,9 we compared weight-specific and global psychosocial concerns between overweight African-American

and Caucasian youth and found similar patterns among the groups (i.e., strong associations between overweight status and body concerns, and weak associations between overweight status and global concerns). It is important to understand similarities and differences in self-perceptions ofAfrican-American and Caucasian overweight youth in order to (1) avoid oversimplified explanations for differential rates of obesity and eating disorders between ethnic groups (e.g., that higher rates of obesity result from lack of weight concerns among African Americans); (2) develop culturally sensitive educational materials and intervention programs that address the needs of specific groups; and (3) develop survey instruments that assess concerns that are relevant to groups other than the dominant culture in an unbiased manner. Thus, the second aim of this study was to compare experiences related to self-image, with a focus on body image, among African-American and Caucasian overweight girls.

METHODS The majority of previous studies of body and self-image among youth have used quantitative research methodolIn the present study, qualitative research methodology was employed in order to increase our understanding of the contextual experiences of overweight adolescent girls. Description o f study sample. T h e study sample included 24 African-American and 26 Caucasian adolescent girls attending five high schools within the St. Paul, M N public school district.These schools were selected for this study because they serve an urban population with great diversity in ethnicity and socioeconomic status. Characteristics of the sample are shown in Table 1. Ethnicity was based on selfidentification (i.e., by the girls).Adolescents were eligible for inclusion in the study if their Body Mass Index (BMI) exceeded the 85th percentile for age and gender.21-23BMI was based on heights and weights assessed in the school clinic by the school nurse or study interviewer prior to acceptance into the study.The majority (n = 40) of the girls had BMI values above the 95th percentile. Differences between the African-American and Caucasian girls for age, height, weight, and BMI were not statistically significant. Recruitment and consent procedures. A variety of recruitment methods were employed in order to decrease the possibility of selection bias and increase the possibility of a diverse sample (e.g., of solely interviewing either a clinical population for whom obesity was a large concern or a population that did not seek care and for whom obesity was not a major issue).The major recruitment methods included displaying flyers on bulletin boards, distributing flyers in school health clinics and health education classes, contacting students who had received weight control counseling during the school year by the nutritionists in the school clinic, inform-

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December 1999

313

Description of study sample.

Mean

SD

Total (n = 50)

Caucasian Girls (n = 26)

African-American Girls (n = 24) Range

Mean

SD

Range

Mean

SD

Range

16.1

1.2

14.0-1 8.0

16.1

1.2

16.1

1.2

Weight (pounds)

21 1.9

43.5

138.0-297.0

202.8

46.3

140.0-342.0

207.2

44.7

138.0-342.0

Height (inches)

64.9

3.4

59.0-71 .O

65.3

4.1

51.5-71.8

65.1

3.8

51.5-71.8

Body Mass Index

34.5

5.3

26.0-48.0

32.8

5.4

24.0-42.0

33.6

5.4

24.0-48.0

Age (years)

14.0-20.0

14.0-20.0

(Weight [kg]/Height2 [m])

ing students using the clinic, and via word of mouth from the students themselves.The purpose of the study was clearly stated in the flyers (i.e., to learn about weight and other concerns among overweight teens and to gather ideas for developing a weight control program).To encourage participation and word-of-mouth recruitment, each participant received a $15 gift certificate to a department store. The study was approved by both the St. Paul School District Research Board and the Internal Review Board of the University of Minnesota. Girls who were interested in the study could either go to the school clinic to obtain more information on the study or contact one of the interviewers by telephone. Girls interested in participating in the study, who met inclusion criteria based on their BMI, received a consent form that they and one of their parents needed to sign prior to their interview. In order to ensure confidentiality, only first names were used in the interviews and in data handling.

Interview procedures. Individual interviews with the adolescents were conducted during school hours in a private room within the school clinic. Interviews were conducted by two graduate students in the health sciences 0 0 and MA) who received intensive training and close supervision from a consultant experienced in clinical research interviewing methods (LF). The interviewers both had past experience working with youth and had strong communication skills. They are both Caucasian, in their twenties, and of average weight. (Interviewer characteristics may impact responses; therefore, they are noted here.) A semistructured interview guide was used. Questions were developed that would provide supplemental information to that collected in surveys. The overall format was based on a semistructured interview guide previously developed by one of the authors (LF) to study psychosocial concerns of children with disabilitie~.~~ Questions were reviewed by the Youth Advisory Board within the Division of General Pediatrics and Adolescent Health at the University ofMinnesota and were pretested on a few adolescent overweight girls. Probing was used if the questions were unclear to the girls and in order to encourage girls to expand on their responses.The interview took approximately 30 to 45 minutes to complete. Questions related to self-perceptions are shown inTable 2.These questions were developed by the research team in accordance with the study objectives and were then reviewed and mod-

ified by the Youth Advisory Board at the Division of Pediatrics and Adolescent Health at the University of Minnesota. It is worth noting that questions were not asked about parity, although it became apparent during the course of the interviews that a few of the participants had children. Interviews were audiotaped, transcribed verbatim, and reviewed by the interviewers for accuracy.

Data analysis. Data were analyzed using principles of content analysis in which an objective coding scheme is applied to the data.25Transcripts were coded in two phases. The aim of the initial coding phase was to organize responses from the entire interview by content area, in order to make the analysis more manageable. Transcribed interviews were read carefully for overall content and identification of major categories of response. Based on the responses, a coding template was developed. Coding for each interview was done by the interviewer and each transcript and coding template was reviewed by the principal investigator (DNS). Coding was done separately for each respondent (i.e., a coding template Table 2.

Question guide for semistructured interviews: assessing self-

perceptions of overweight adolescent girls. I would like to ask you questions about how you feel about yourself and about how others treat you. 1. How would you describe yourself? 2. When you think about your body or weight, what stands out for

you? 3. Tell me how it feels or what you think about when you look in the

mirror. 4. How do you feel about your body? 5. How do you feel about your weight? 6. What features or characteristics that you have give you a sense

of pride? 7. Are there situations that make you feel self-conscious in

general? About your body in particular? 8. Describe the ideal you. Do you think you are or could become

that person? 9. Of all of the concerns or issues in your life right now, how would

you rate weight as a concern of yours?* 'This question was added after reviewing the first 10 to 15 interviews; therefore, data are not available on this item for the entire population.

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was produced for each participant) in which phrases from the transcripts were placed into the coding template according to the coding categories of the established template.The coding system was pilot tested on the initial transcripts and slight revisions in the coding system and the interview process (including the addition of one question) were made.Ten percent of the interviews (n = 6) were randomly selected to be double coded and consistency between the two coders was assessed using the formula number of agreementdtotal numIntercoder reliabilber of agreements plus di~agreements.'~ ity was 87.5%,indicating acceptable consistency in coding by the two coders. Due to the large amount of data collected, the first stage of coding was aimed at organizing the material into broad categories that were derived from participants' responses.The second phase of coding was of a more analytical nature. Furthermore, in the second phase, only categories of relevance to this paper were included. As we focused more on the analysis for this study, relevant categories were refined slightly (e.g., some were combined while others were broken down further).The refined categories, which form a basis for the analysis in this study, include general description of self; weight-specific self-perceptions; nonweight-related self-perceptions; situations in which one feels self-conscious; perceptions of ideal self; perceived ability to become ideal self; and weight as an issue. Responses from each girl falling under each category (e.g., general description of selt) were grouped together. Using a word processing program, these responses were moved into a new template. Each interview was numbered and responses were entered into this template by number, thus allowing for the determination of the number of students expressing an idea. Responses were read and reread and themes that emerged from the data under each category were identified. For example, under the category of "situations in which one feels self-conscious," some of the themes that were identified included "swimming or wearing a swimsuit,'' "trying on clothes," and "being around thin people." Under the category of "description of self," responses were examined for "main focus of response" in order to assess whether weight was the dominant focus of their self-description, and "overall tone of response" in order to assess whether their self-description tended to be positive or negative. The final themes were discussed and reviewed at length between the investigators and modified until agreement was reached. Each of these themes was then assigned a code and a codebook was deve1oped.N of the templates were independently coded by the principal investigator and an interviewer, and intercoder reliability was assessed using the previously described formula and found to be 94.6%. After discussion of the disagreements, agreement was increased to 100%.

related self-perceptions; situations in which one feels selfconscious; perceptions of ideal self; perceived ability to become ideal self; and weight as an issue. Quotations from the girls are presented that exemplify major themes.

Description of self. Responses to the question "How would you describe yourself?" were examined for main focus of response and overall tone of response.The majority of the girls (n = 36) described themselves in terms of their weight. Weight was the dominant focus of their self-descriptions for half of the study population (n = 24): U m , I'd describe myselj as overweight ...Sometimes, I'm down on myselfabout it, you know. Especially when I g o trying on clothes and stufand, yeah, that's hard.

For others, weight issues were mentioned but were not the dominant focus of their responses (n = 12): U m , overweight, long haiu, blue eyes,fair skin,freckles, no glasses or braces, though I need both. Shoot, I'm kind ofbasing this one on how I type it over the Internet. They'll be like, what do you look like?

One-fourth of the girls (n = 13) discussed other aspects of their appearance and their personality and did not mention weight issues in describing themselves. Responses were also examined for overall tone in order to determine whether the girls tended to describe themselves in a positive or negative manner. The overall tone of their responses tended to be positive or mixed: I'm a nice person. I'm easy toget along with. Um.. .I usuallyfeel really good about mysex regardless of weight.. . .I know that I'm overweight, but I try not to let it bother me.

However, some of the girls' responses were more negative. Some of the Caucasian girls described themselves with one word: "fat." Others discussed themselves in terms of negative interactions with others: Neutral. I don't always know like, i f 1 like myse& There are days when I used to like...I don't even want to be in this world. I don't even want to be around these people, you know, who make fun of me, people who think: 'Oh, she's sofat.'You know, like I have to be like everybody else. Like I have to be one of the girls at school that are really skinny and have a nicejgure or whatever, you know. But other days I feel, who cares, you know. ..it's not like I'm trying to impress somebody.

RESULTS

Weight was the main focus of their response for fewer African-American girls (n = 9) than Caucasian girls (n = 15). Furthermore, only 2 of the 24 African-American girls described themselves in primarily negative terms as compared to six of the Caucasian girls.

The results are presented by examining the themes that emerged in each of the following categories:general description of sele weight-specific self-perceptions; nonweight-

Body image: weight-specific self-perceptions. The majority of both African-American and Caucasian respondents described their body and shape in negative terms

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315

...I see it like this, ifsome guy doesn't like you or some girl doesn't like you.. . because you are overweight, then you don't need to be bothered with them kind of people anyway.. . When I was in the eighth grade I used to be like 2 5 0 pounds and I lost all that weight, I was down to like 165-1 7 0 . 1 was really proud of myself but I was really trying so hard and it was so hardfor me to keep that weight o f I was eating like barely nothing. I wasgoing through the day eating like half a piece of toast in the morning and some fruit and that is like it. And I was like why am I starving myself to please other people? I f I am naturally big, Iguess I willjust naturally be big. It doesn't really bother me anymore. Basically, I say now I am trying to lose that 5 pounds, that 5 to 10pounds now. I f 1 don't exceed 200, I'm cool. I am pretty much cool.

(Table 3).Some of their remarks indicated extreme body dissatisfaction: ...my legs, my hips, my stomach, pretty much.. .I am like really disgusted how I look because it'sjust bulging. You know bulges out and it's really ugly to me. It's like, I really don't like the way I look ... I wish I could cut my stomach o f

Many of the negative feelings related to social interactions and their fears of how they would be viewed by others: ...I hold myselfback a lot because I'm afraid of what people will think about my overweightness and stujf..I want to get rid of it [her weight]...1 don't want to be like a size perfect, perfect model size or nothing like that, you know. Just down to where I feel comfortable. Where I cango aroundpeople and not ... have it constantly on my mind about thisperson isgoing to think this, you're this, and you're that, and I can't do this. Because, I mean like at Wlleyfair [amusement park] I'll be there and I'll be worried that I won'tfit in the rides.

Seven of the African-American girls made positive comments about their body as compared to only three of the Caucasian girls. One girl commented that she wears her weight well. Another African-American girl stated that her "bust and butt" gave her a sense of pride and that she liked her curves:

Other comments, while negative, were made with some type ofjustification or stipulation. For example, the girls indicated that although they were not satisfied with the way they looked, they tried not to let it bother them too much:

Not to be mean or anything, but most skinny girls don't have any curves. So it is like, okay, I am kind ofproud of that. I've got curves.. .sometimes too much curves, but I have some.

Positive nonweight-related self-perceptions. The majority of the girls (n = 30) made at least one positive comment on their nonweight-related appearance, in particular when describing features that "give them a sense of pride" or in describing themselves (seeTable 3). Features mentioned included "being tall," "my face and my smiles," "dimples," "hair:' "good poise," "my eyes," "nice skin," "being pretty," "overall appearance," and "skin color." However, comments tended to be somewhat sparse, in contrast to their rich comments on issues related to body shape and weight.

I think I'd like it better if it [body] was smaller. I don't hate it, because I know it, it's not like it's my body'sfault, it's my mind. It's not, I mean, I can't hate it 'cause it's mine. Ijust don't particularly like the phase it is in right now.

Struggles of body acceptance arose in which the girls considered to what extremes they were willing to go to be thinner, why, and for whom. As one African-American girl said:

Table 3.

Self-perceptions of overweight adolescent girls. African Americans (n = 23) n

WeightIShape Self-Perceptions Mainly negative comments Only negative comments but with stipulations (e.g., "but I'm big-boned") Negative and positive comments Only positive comments Nonweight-Related Self-Perceptions Positive comments made about appearance Negative comments made about appearance Positive comments made (e.g., about personality, talents, or activities with which involved) Negative comments made (e.g., about social difficulties, low self-esteem)

%

Caucasians (n = 26) n

%

Total (n = 49) n

%

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Neumark-Sztainer et al./ISSUES O F SELF-IMAGE

Both African-American and Caucasian girls appeared to feel more comfortable discussing the positive self-perceptions that they had of themselves that were not related to appearance. Only one of the girls did not say anything positive about herself.Thus, although weight had a large negative impact on how they viewed themselves, they were able to identify positive aspects of their personalities, talents, and roles that they played.These were described throughout the course of the interview, but in particular in response to the questions on features that give a sense of pride and overall description of self.The majority of the positive comments related to personality characteristics. Girls described themselves as "outgoing, intelligent, and exciting,""fun, different, and just outgoing," "good sense of humor," "nice, smart, kind, generous," and "I treat people the way I like to be treated." Girls also took pride in their musical talents, athletic abilities, and other activities with which they were involved.These activities/talents were important to the girls and may have influenced how they felt about themselves. The girls also indicated that they took pride in being able to help others, in their own children, in being healthy and taking care of their health through diet and exercise, in their jobs, and in their school performance.They took pride in the fact that they were able to overcome challenging situations: I'm a good mom, yeah, I like children and I'm a good student, I get A's in school. Going as far as I have in school, 'cause I have friends that dropped out and stuff and being able to say no to dgerent things, like drugs and stuff..being able to stand up to people.

Ethnic differences in positive nonweight-related self-perceptions did not emerge.

Negative nonweight-specific self-perceptions. Few girls (n = 4) made negative comments with regard to their appearance that were not weight related (see Table 3). More girls discussed negative self-perceptions that were not related to appearance (n = 14).Among the more prominent negative self-perceptions were personality characteristics such as low self-esteem, school-related difficulties, difficulties in social interactions with peers, fatigue, and health concerns. They most commonly mentioned difficulties with social interactions due to being overweight: But now I don't have a crowd.. .the closest to a crowd I have is the people who are in dance and (a) I'm the biggest person in dance class and (b) the people who are my friends in dance aren't.. .belong to other quote unquote "cliquesJ'or whatever. But Ifind myselfbeing morefriends with adults than with kids.

Issues of low self-esteem were also raised by some of the respondents. One girl discussed the painful impact of being mistreated by others on her self-esteem and on the selfesteem of overweight people in general:

...I know there are a lot ofpeople who are ovenueight, or think that they're overweight, they have very low self-esteem and stuff like that. And, I think that part ofthe reason is that because, I mean you're trying to build up your sel$esteem and yet they just keep knocking it down, knocking it down, knocking it down.. .So, it's like the harder you s t r u ~ l ethefarther, the farther that you fall behind. And then eventually you have no self-esteem and sometimes you break down. Sometimes you close yourselfout ofthe world. Differences in negative nonweight-related self-perceptions between the African-American and Caucasian girls did not emerge.

Situations in which respondents feel self-conscious. A number of recurrent themes regarding situations in which the girls felt self-conscious were apparent. These included wearing a swimsuit/swimming, being around thin people, wearing certain clothes, trying on clothes, situations in which other people make comments or stare, being around guys, gym or exercise class, and food situations with others. Situations seemed to fall into two broad and somewhat overlapping categories: (1) situations in which "I show more of my body than I like to" and (2) situations involving interactions with others. The situations described by the girls demonstrate the difficulties and pain felt by these girls in different activities. Both Caucasian and African-American girls discussed feeling self-conscious in situations in which too much of their body was revealed or otherwise related to clothes issues. By far the most frequently mentioned situations were those involving wearing a swimsuit (n = 18). The girls talked about their desire to wear a tee-shirt over their swimsuit in gym at school and the fact that their teachers would not allow it: Swimming suits ...at school. We have to go swimming. And he said we have to wear swimsuits. And I don't want to wear a swimsuit. I asked him nicely, 'please do I have to wear a swimsuit?' 'Yes, you got to wear a swimsuit.. .'And the only siuimsuit Igot is one that shows my back and I don't want it to show my rolls-that's gross. And then people going to call me Free Willy or something.

Six African-American girls discussed feeling self-conscious in certain clothes in comparison to only one Caucasian girl. These girls indicated their frustration at not being able to wear clothes like their peers and discussed feeling self-conscious in clothes that revealed too much of their body: I walk around school and see all these girls with nice clothes on and really thin and Ifeel I can't even wear all those clothes. I can't because I'm overweight.

Caucasian girls (n = 6) were more likely to discuss feeling self-conscious around thin people than African-American girls (n = 1):

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When I'm home I don'tfeel so bad, but when I'm in school and when I'm around people who are thin I feel overweight the most.

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317

Similar responses were found among the African-American and Caucasian girls.

...when you're in a roomfull ofskinny people and there4 not another person like you.. .

Ideal self. In describing their ideal self, all of the girls mentioned weight-related issues. For the majority of the girls (n = 32), weight was the dominant focus of their responses. Many of the girls qualified their statements by indicating that although they wanted to lose weight, they did not wish to be too thin, or they still liked themselves as they were: The ideal me would be like, hmmm, no, I don't want to be too skinny. I don't want to look like a twig. I want to still have some curves. I like everything about me, it is just that I think that I could be skinnier. I want to be about 160. 1 wouldn't want to be like, really small but, you know, not really big. I mean, just like, you know, a nice medium weight, you know. I want to look.. . healthy.. .like nice. Nothing, you know, that makes me look like, oh, I'm this supermodel and I'mgonna woo you over yourfeet.. ..You know,just normal, you know. Not really normal but just something nice you know.. .comfortable.

In general, responses from the African-American and Caucasian girls tended to be similar. However, eight AfricanAmerican girls indicated that they like the way they are, in spite of their weight, as compared to only two Caucasian girls.

Perceived ability to become ideal self. The majority of the girls felt that they had the ability to become their ideal self. Only one of all of the respondents clearly said that she did not have the ability and another five had mixed feelings. Many of them indicated that they could become their ideal self if they tried hard enough and/or if they had some help: I think $1 really set my mind to it, I could. But it'd take a lot of work,

you know. A lot ofefort. Yeah, $ 1 really try. Ifsomebody would help me--actually would help me try to lose this weight. I wouldgive them anything they wanted.

Weight as an issue. In response to the question "Of all of the concerns or issues in your life right now, how would you rate weight as a concern of yours? (on a scale from 1 to lo)," nearly half of the girls who were asked rated weight as a high concern.* However, an equal number of girls stated that although weight issues were important to them, they had other, more pressing concerns: Middle. M y top concern is reallygraduating. I could care less flgraduated big as a house or as little as an ant; it doesn't matter to me.

............................................. * T h ~ squestion was inserted after review of the initial 10 to 15 1ntervlews.Therefore, data were not available for all respondents.

DISCUSSION The findings clearly demonstrate the multilayered complexities of the situation facing overweight adolescent girls that need to be addressed by clinicians working with overweight youth and by researchers studying the psychosocial concerns and issues of self-image among this group. Many of the girls appeared to have positive self-perceptions in spite of extreme weight and body-image c0ncerns.A comparison of body- and self-image concerns among African-American and Caucasian girls revealed more similarities than differences. Most of the girls in the present study expressed strong concerns regarding their body shape and size and high levels of body dissatisfaction. In discussing their bodies, they used terms such as "disgusted" and "ugly."They talked about wanting to get rid of their fat by cutting it off.They discussed the difficulties they faced in wearing certain clothes and the difficulties they faced in social interactions. In discussing their ideal self, weight was consistently raised as something they would like to change. The results of the present study confirm our previous findings and those reported by others using survey methodology, in which overweight youth indicated strong body d i s s a t i s f a ~ t i o n . ~ ~ ~ ~ ~ ~ ~ The findings in the present study also help us to better understand the inconsistencies that appear in the literature with regard to associations between overweight status and nonweight-specific aspects of self-image.8 Comparisons of overweight and nonoverweight youth with regard to issues of self-image and psychosocial concerns are often done with brief global measure^,^ yet our findings suggest that there are various facets and layers underlying one's self-image that may be difficult to detect with these measures. Inconsistencies across studies may differ in accordance with the setting, - the overall focus of the survey instrument, and the wording of specific items. In interviewing these girls, we were simultaneously struck by (1) the difficulties felt by these overweight girls living in a thin-oriented society and (2) the realization that being overweight was only one aspect, albeit a significant one, in their 1ives.The girls' responses showed that being overweight was a central part of their life that negatively impacted their own body image and social interactions with others. However, nearly all of the girls had something positive to say about themselves and their lives. Furthermore, in addition to their weight concerns, these youth expressed concerns common to many adolescents regardless of their weight (e.g., graduating from high school), and they discussed issues that were of more concern to them than their weight.Thus, while weight clearly was an important issue to these youth, it was not the only issue, and numerous factors appeared to be working to influence the various aspects of their selfimage.

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An important aim of the study was to compare AfricanAmerican and Caucasian overweight adolescent girls with regard to their body- and self-image issues. Here, too, the findings supported previous findings from survey data in which we found similar patterns of associations between overweight status and psychosocial concerns among both African-American and Caucasians, albeit slightly stronger associations between weight concerns and overweight status In the present study, both Africanamong the Cauca~ians.~ American and Caucasian overweight girls expressed concerns about their body shape and size, but African-American girls were more likely to also discuss the positive aspects of their bodies than the Caucasians.Thus, in comparing groups of different ethnicities, it may be more informative to include both positive and negative measures of body and self-image and to examine them separately. As in the present study, Kumanyika et al. reported that overweight African-American women perceived themselves as overweight and wanted to lose weight, yet approximately 40% of these women considered their figures attractive or very attractive.I7They concluded that the social environment ofAfrican-American women may be less negative about obesity than that of Caucasian women and that being overweight is not necessarily synonymous with being unattractive; yet, to say that this population is uninterested in weight control appears too simplistic." Adolescents tend to be vulnerable to social pressures and may be more exposed to the dominant culture than their parents (e.g., in their school and via the media).Therefore, one might expect the values of the dominant culture, which discriminate against overweight persons, to be more pervasive among adolescents than among adults. Overall, in making comparisons across ethnicity, we found numerous similarities between the overweight AfricanAmerican and Caucasian girls. Both African-American and Caucasian girls tended to describe themselves in terms of their weight, indicated their desire to be thinner, expressed dissatisfaction with their body shape and body size, and discussed situations in which they felt self-conscious due to their weight. In drawing conclusions from the findings, a number of factors need to be taken into account. The study design allowed for us to study emerging themes regarding issues of body and self-image and to explore the experiences of the girls who participated in the study. However, the study population was not necessarily representative of overweight adolescent girls. Since the purpose of the study was made clear at the time of recruitment, girls who were extremely ashamed of their bodies, or alternatively did not view themselves as overweight, may not have volunteered to participate. There may also have been differential patterns in willingness to participate across ethnicity. Therefore, extrapolations to other populations, without careful consideration of potential differences between the individuals and their social and physical environment, may be inaccurate. Even in understanding the psychosocial make-up of the study participants, the focused nature of participant recruitment and of the questions used in the interviews should be taken into account as

they may have guided responses. For example, when asked to describe themselves, subjects may have been more likely to include weight-related issues in this study than in an interview for which they did not have to be overweight to be eligible. Care should be taken in making comparisons across ethnicity as the Caucasian and African-American girls were not matched for sociodemographic characteristics. Information on socioeconomic status was not collected; therefore, we cannot state whether the groups differed with regard to their socioeconomic background. Furthermore, information was not collected on parity, which may impact self-image and differ across ethnicity. In addition, it should be noted that none of the research team members involved in data collection and analysis were overweight or African American.This may have impacted both the type of data collected and the manner in which the data were analyzed. For example, since the girls were overweight, they may have been more open had the interviewers also been overweight. Similarly,African-American girls may have been more open with African-American interviewers. In the data analysis stage, overweight researchers may have been more sensitive to some of the more subtle comments made by the girls and African-American interviewers may have been able to pick up on more subtle cultural factors among the African-American girls. Since the interviewers coded their own interviews, they were not blinded to the ethnicity of the girls, and although stringent coding strategies were employed, this may also have had an impact on the analysis. Finally, due to the nature of the study, a comparison group of nonoverweight youth was not included. Research has shown that normal and underweight girls also have weight and body shape concern^.^ Future qualitative research should examine weight concerns among overweight and nonoverweight adolescents to see how different aspects of self-image vary across weight status.

IMPLICATIONS F O R RESEARCH A N D PRACTICE The findings have implications for health care providers working with overweight youth. Clinicians often ask whether and how the topic of weight should be addressed in light of the sensitivity of weight issues, low success rates in achieving weight loss, danger of eating disorders, and time required for counseling. For the most part, the girls we interviewed said that they enjoyed discussing these issues with the interviewers. Some of them commented that this was the first time they had discussed these issues at length. Through an understanding of the complexity of the situation facing overweight youth, we believe that clinicians and educators will be more empathetic to the issues at hand.As many of the negative statements made by the girls focused on interactions with others, health care providers and educators may want to consider strategies for reaching peers, family members, and teachers with messages about their influence on the overweight adolescent? development. The findings also have potentially important implications for research on psychosocial concerns among overweight

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youth. As described above, ethnic differences were more apparent for positive descriptors of weight than for negative descriptors.Thus, surveys may want to separately assess positive and negative body-image attitudes.The use of separate scales to assess body satisfaction and body dissatisfaction would allow for a more informative comparison across ethnicity.While the body dissatisfaction scale of the Eating Disorders Inventory includes statements such as "my stomach is just right," these items are reversed in scoring and ~~ scaled together with statements phrased n e g a t i ~ e l y .In assessing self-image among adolescents, surveys often use global measures such as Rosenberg's self-concept scale30 o r individual question items9 due to restraints on the number of questions that may be included in a survey. If such global measures are used to assess associations between BMI and self-image, caution should be taken in interpreting the findings. If possible, scales assessing different areas of perceived competency should be used rather than scales assessing overall self-esteem. For example, French et al. examined associations between BMI and both global and domain-specific self-esteem using the Harter Self-Perception Profile for Adolescents, which is comprised of 36 items assessing global feelings of self-worth and self-esteem in eight subdomains They found significant associrelated to adolescent life.27,31 ations with some of the domains but not with o t h e r ~ . ~ ' W e also found the responses to the question "How would you describe yourself?" to be informative, and researchers developing surveys might consider the inclusion of such a shortanswer question. Since both overweight and nonovenveight youth may be faced with weight concerns, another question of interest to ask of all youth is "Of all of the concerns or issues in your life right now, how would you rate weight as a concern of yours?" Responses could be closed ended (e.g., on a scale of 1 to 10) and/or open ended to allow for comments. Finally, a combination of both qualitative and quantitative research studies may be advantageous in that they tend to complement each other. Qualitative methodologies help us to understand the experiences of overweight youth and the language and manner that they use to describe themselves, while surveys allow us to study and compare large and diverse populations.

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2. Horner TN, Untermohlen V. A multivariate analysis of psychological factors related to body mass index and eating preoccupation in female college students. J Am Coll Nutr 1993;12:459-65. 3. Wadden TA, Foster GD, Stunkard AJ, Linowitz J R . Dissatisfaction with weight and figure in obese girls: discontent but not depression. Int J Obes 1989;13:89-97. 4. Rumpel C, Harris TB. The influence of weight on adolescent selfesteem. J Psychom Res 1994;38:547-56. 5. Friedman MA,Wilfey DE, Pike KM, Striegel-Moore R H , Rodin J.The relationship between weight and psychological functioning among adolescent girls. Obes Res 1995;3:57-61. 6. Hoerr SL, Kallen D, Kwantes M. Peer acceptance of obese youth: a way to improve weight control efforts. Ecol Food Nutr 1995;33:203-13. 7. Kaplan KM,Wadden TA. Childhood obesity and self-esteem. J Pediatr 1986;109:367-70. 8. French SA, Story M, Perry CL. Self-esteem and obesity in children and adolescents: a literature review. Obes Res 1995;3:479-90. 9. Neumark-Sztainer D, Story M, French S, Hannan P, Resnick M, Blum RW. Psychosocial concerns and health-compromising behaviors among overweight and non-overweight adolescents. Obes Res 1997;5:237-49. 10. Crabtree B, Miller W. Doing qualitative research. Newbury Park, CA: Sage, 1992. 11. Morse JM, Field PA. Qualitative research methods for health professionals. 2nd Ed.Thousand Oaks, CA: Sage, 1995. 12. Coffey A,Atkinson P. Making sense of qualitative data: complementary research strategies.Thousand Oaks, CA: Sage, 1996. 13. Maykut P, Morehourse R . Beginning qualitative research: a philosophic and practical guide. London:The Falmer Press, 1994. 14. Betts N, Baranowski T, Hoerr S. Recommendations for planning and reporting focus group research. J Nutr Educ 1996;28:279-81. 15. Nichter M, Ritenbaugh C, Nichter M,Vuckovic N,Aickin M. Dieting and "watching" behaviors among adolescent females: report of a multimethod study. J Adolesc Health 1995;17:153-62. 16. Troiano RP, Flegal KM, Kuczmarski RJ, Campbell SM, Johnson CL. Overweight prevalence and trends for children and adolescents. Arch Pediatr Adolesc Med 1995;149:1085-91. 17. Kumanyika S,WilsonJ, Guilford-Davenport M.Weight-related attitudes and behaviors of Black women. J Am Diet Assoc 1993;93:416-22. 18. Walcott-McQuigg JA, Sullivan J, Dan A, Logan B. Psychosocial factors influencing weight control behavior of African American women. West J Nurse Res 1995;17:502-20. 19. Desmond SM, Price JH, Hallinan C, Smith D. Black and White adolescents' perceptions of their welght. J Sch Health 1989;59:353-8.

ACKNOWLEDGMENTS

20. Parker S, Nichter M, Nichter M,Vuckovic N, Sims C, Ritenbaugh C. Body image and weight concerns among African American and White

We wish to express our gratitude to the study participants who have enlightened us through the sharing of their experiences.We are also grateful to Irene Alton, M.S., R.D., who was responsible for recruitment.

adolescent females: differences that make a difference. Hum Org 1995;54:103-14. 21. Himes JH, Dietz WH. Guidelines for overweight in adolescent preventive services: recommendations from an expert committee. Am J Clin Nutr 1994;59:307-16. 22. Must A, Dallal GE, Dietz WH. Reference data for obesity: 85th and 95th percentiles of body mass index (wt/ht2) and tricep skinfold

REFERENCES

thickness.Am J Clin Nutr 1991;53:839-46. 23. Must A, Dallal GE, Dietz WH. Reference data for obesity: 85th and

1. Sobal J, Nicolopoulos V, Lee J. Attitudes about overweight and dating among secondary students. Int J Obes 1995;19:376-81.

95th percentiles ofbody mass index (wt/ht2)-a Nutr 1991;54:773.

correction.Am J Clin

320

Neumark-Sztainer et al./ISSUES O F SELF-IMAGE

24. Faibisch L. Insensitivity, harassment, and discrimination: a hostile psy-

28. Brown KM, Schreiber GB, McMahon RP, Crawford P, Ghee KL.

chological, social and educational climate for adolescents with physi-

Maternal influences on body satisfaction in Black andWhite girls aged

cal disabilities. Doctoral dissertation, Harvard University, Cambridge,

9 and 10:The NHLBI Growth and Health Study (NGHS).Ann Behav

Massachusetts, 1995.

Med 1995;17:213-20.

25. Berg B. Qualitative research methods for the social sciences. 3rd Ed.

29. Garner DM, Olmstead MP, Polivy J. Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and

Needham Heights, MA: Allyn and Bacon, 1998. 26. Miles MB, Huberman AM. Qualitative data ana1ysis.Thousand Oaks,

bulimia. Int J Eat Disord 1983;2:15-34. 30. Rosenberg M. Society and the self-image. Princeton, NJ: Princeton

CA: Sage, 1984. 27. French SA, Perry CL, Leon G R , Fulkerson JA. Self-esteem and change in body mass index over 3 years in a cohort of adolescents. Obes Res

University, 1956:305-7. 31. Harter S. Manual for the self-perception profile for adolescents. Denver: University of Denver, 1988.

1996;4:27-33.

NEWS

NEWS

NEWS

NEWS

NEWS

WHAT:

Society for Nutrition Education's 2000 Annual Meeting: Marketing and Communications Strategies for the New Millennium.

WHEN:

July 22 - 26,2000

WHERE:

Charleston, South Carolina The seat of charm, grace, and an incredibly stimulating meeting of nutrition educators!

WHY:

To gain new insight, appreciation and understanding of innovative and effective ways of: Marketing our talent, Extending our reach, and Communicating the science of nutrition in an era of dramatic change, serious challenges, and infinite possibilities!

For more information or to be added to the mailing list for the 2000 Preliminary Program, contact Mary Meegan at 301.656.4938 or via email at [email protected].