Preadolescent Body Image and Body Mass Index
by
Megan Hauser
A Senior Honors Project Presented to the
Honors College
East Carolina University
In Partial Fulfillment of the
Requirements for
Graduation with Honors
By Megan Hauser
Greenville, NC
May 2015
Approved by:
Dr. Elizabeth Wall-Bassett
Department of Nutrition Sciences
College of Human Ecology
Preadolescent Body Image and Body Mass Index
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Abstract
Physical and psychological changes occur during middle childhood and the time
preparing for adolescence. Healthy body image is a key factor in developing healthy physical
and psychosocial habits among preadolescents. There is more documented research on body
image and lifestyle habits among females. The purpose of this research was to investigate Body
Mass Index (BMI) and perceived body image among male and female adolescents, and to
investigate if nutrition education lessons regarding healthy lifestyles can influence body image.
Six preadolescent children’s weight and height were measured using a stadiometer in
order to calculate Body Mass Index (BMI) (kg/m2) and assess BMI categories (underweight,
normal, overweight, obese). An evaluation of children’s personal body image using the Gardner
13-figure schematic contour scale and the CDC 13-item body image questionnaire was used
before and after nutrition education lessons were presented. Four 30-minute nutrition education
lessons focused on healthy eating habits, physical activity, and self-esteem.
All participants had low self-esteem related to body image during the nutrition education
lessons. All participants reported a positive body image or total body image score at pre- and
post-test. When investigating body image discrepancy, participants in each BMI category
reported slight differences in desire to change their body figure. Body image discrepancy was
lower after interventions were conducted and four of the six participants increased in their total
body image scores. Future research and interventions aimed at targeting children and adolescents
can encourage healthy living and positive body image.
Preadolescent Body Image and Body Mass Index
Introduction
Overall health has become an important topic in the United States, and the focus on
adolescence and preadolescence has started to gain importance, as evidenced by First Lady
Michelle Obama’s “Let’s Move” Healthy Eating program13 and other healthy living campaigns.
Body image is described as an individual’s overall appearance6. Studies have shown that
adolescent and young adult body image can have a large effect on overall health23, however it is
easy to acquire a negative body image and many studies have found low positive body image
among adolescents and young adults10. According to Wood29, preadolescence is defined as the
period of development just preceding adolescence, normally between the ages of nine and
twelve.
Studies have debated the necessary factors that need to be taken into consideration when
approaching research with children and adolescents and their perceived body image and how to
provide successful interventions; mainly including a deeper exploration of sociocultural factors
that are associated with body image, associations between Body Mass Index (BMI) and Body
Image Discrepancy (BID), and overall improvement of body satisfaction among males and
females16. However, low body image among preadolescent children has been found and
psychological research suggests that adolescence is the time to introduce the information of
positive body habits so that it can be of practical use in the future9. Researchers have focused
studies on children, such as those by Kelly, Neumark-Sztainer, and Eisenberg5, 11, 16 and have
investigated body satisfaction among male and female adolescents, but they identified that there
is a need for a better understanding of appropriate interventions and ways to approach the topic
of body satisfaction that children could comprehend and apply to their lives.
3
Preadolescent Body Image and Body Mass Index
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The purpose of this study was to investigate BMI and body image in preadolescents
before and after nutrition education lessons.
Materials and Methods
Methods
The study was conducted in a metropolitan Southern town at a public afterschool
program. The Principal Investigator worked with staff and the Director of the program to recruit
students for the study from the 41 students in third to fifth grades.
The staff designated two evenings for the Principal Investigator to briefly explain the
study, answer questions, and inform parents about study participation. Consent forms were
distributed to parents as they picked up their children from the afterschool program. Once
consent forms were returned, assent was obtained by nine children. Three of the nine children
declined participation after the first nutrition education lesson. The sample size consisted of five
female students and one male student in the third and fourth grade.
Measurements, surveys, and nutrition education lessons were conducted during normal
afterschool hours, in a private area away from nonparticipants. Data collection took place over
four weeks during February and March 2015.
Measurements
Heights and weights were measured in inches and pounds and converted to kilograms and
meters to calculate BMI (kg/m2). Heights were measured with a portable stadiometer and
average weights were taken from three consecutive recordings using a digital scale (Tanita TBF522-W). Heights, weights, and ages (in years) were entered into QuesGen Systems, Inc. Pediatric
Percentile Calculator19 to measure the BMI percentile and z-score of each participant. Each
percentile was then coded as underweight (less than 5%), normal (5-85%), overweight (86-95%),
Preadolescent Body Image and Body Mass Index
5
or obese (greater than 95%) according to the Center for Disease Control Child Growth
Standards1.
Surveys
Surveys were conducted using selected questions from the CDC 13-item body image
questionnaire9 and the Gardner 13-figure schematic contour scale2. The selected questions
measured perceived body mass index and level of body satisfaction among each participant, and
were also chosen based on acceptable level of comprehension for the study participants. The
survey used in this study included ten questions, listed in Tables 1. Participants were asked to use
schematic figures (Figure 1) and a pictorial likert scale (Figure 2) to respond to the survey
questions. Pre-testing occurred when height and weight measurements were taken, one week
before beginning the nutrition education lessons. Participants were asked to complete the same
survey questions as the post-test, one week after the last nutrition education lesson. Body image
discrepancy, feelings about personal body image and how they feel others view their body
image, and a total body image score were gathered from the surveys.
Preadolescent Body Image and Body Mass Index
Survey Questions
1. What figure do you think you look like?
2. What figure would you like to look like?
3. How do you feel about the way you look?
4. How do you feel about buying clothes?
5. How does media make you feel about yourself?
6. How do you feel when your friends talk about
how they look?
7. How do you feel when your family talks about
how they look?
8. Do you need to change the way you look?
9. Have you ever dieted?
10. Have you ever been told you need to change
your weight?
Table 1. Pre- and Post-Intervention Survey Questions
6
Preadolescent Body Image and Body Mass Index
7
Figures 1. Schematic figures used to measure Body Image discrepancy with the
questions “Which figure do you think you look like now?” and “Which figure
would you like to look like?”
5
4
3
2
1
Figure 2. Scale used for responses for questions 3-7 in Pre- and Post-Intervention Surveys.
Preadolescent Body Image and Body Mass Index
8
Questions 1 and 2 were used to measure Body Image discrepancy. If there was any
difference between the figure chosen in question 1 and the figure chosen in question 2, there was
discrepancy in perceived body image. Participants were asked to answer questions 3 through 7
using the pictorial likert scale, with 1 depicting “Very Sad” to 5 depicting “Very Happy.” The
response choices for questions 8 through 10 were either “Yes” or “No.” “Yes” answers were
coded with a value of 0 and “No” answers were coded with a 1. Total body image score was
calculated from the total sum of questions 3 through 10. The lowest possible total body image
score of ‘8’ reflects negative responses and a very low body image. A median score of ‘13’
reflects an average body image. The maximum score of ‘28’ reflects high body image.
The East Carolina University Institutional Review Board reviewed and approved this
study.
Intervention
One nutrition education lesson on healthy lifestyle habits and positive body image was
delivered each week for four consecutive weeks. The topics were designed to provide
information and resources in an interactive and personal format with each lesson lasting
approximately 30 minutes. The four lesson topics included two lessons on Healthy Eating
Habits, and two lessons on Body Image. These topics included tips for planning meals and
choosing healthier foods, encouraging physical activity, and having positive attitudes.
Resources from the United States Department of Agriculture MyPlate4 and Let’s Move!
Take Action Kids13 programs provided information, aided development of activities, and helped
focus learning objectives for the Healthy Eating Habits lessons. The Healthy Eating Habits
lessons included information on identifying and selecting foods from the food groups, estimating
appropriate portion sizes, making healthy food choices including trying new fruits and
Preadolescent Body Image and Body Mass Index
9
vegetables and drinking plenty of water, being physically active throughout the day and breaking
up TV time, and how to help prepare dinner at home. Participants provided examples of
preferred or usual food items that corresponded to recommendations such as MyPlate and within
food groups, at-home activities they felt they could do while watching television or other
sedentary activities to help increase movement.
During one of the Body Image lessons, participants discussed media influences on Body
Image, and ways to promote a positive body image and encourage self-esteem. Participants were
challenged to create their own promotional media advertisement for healthy food choices, being
active, and positive influences on body image. During the other Body Image lesson, the
definitions of self-esteem and body image were provided and there was an open discussion to
explore the participants’ perception of what makes each of them unique, to brainstorm ideas that
can help them appreciate their unique qualities, and to have a more positive outlook.
Results
Twelve parents provided consent for their children, and nine children provided assent.
Three of nine children declined participation after the first nutrition lesson. The resulting sample
size consisted of five female students and one male student all in either the third and fourth
grades. Three participants had a normal BMI, two participants were overweight, and two
participants were considered obese as shown in Table 2.
Gender
F
F
F
F
F
M
Age
10
9
8
10
9
8
Grade
4
4
3
4
3
3
BMI (kg/m2)
17.9
25.4
17.3
20.8
25.5
18
BMI
Percentile
65
98
75
89
98
85
Table 2. Table of the preadolescent participants
BMI Category
Normal
Obese
Normal
Overweight
Obese
Overweight
Preadolescent Body Image and Body Mass Index
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Pre-test and post-test survey data is presented in Tables 3, 4, and 5. All participants had
low self-esteem related to body image during the nutrition education lessons. Participants had
negative feelings when asked, “How do you feel when your friends talk about how they look?”
and “How do you feel when your family talks about how they look?” (Questions 6 and 7) Three
participants responded with 1 = “Very Sad” and 2 =“Sad” to both of these questions, as shown in
Figures 3 and 4.
Preadolescent Body Image and Body Mass Index
11
Responses
A
1. What figure do you
think you look like?
1 male
2. What figure would
you like to look like?
Post
Pre
1 Female, 1
male
C
Post
1 Female
1 Female, 1 1 Female, 1
Male
Male
Pre
0 1 Female
3 Females
3 Females
D
Post
4 Females
0 1 Female
Pre
E
Post
Pre
F
Post
Pre
G
Post
Pre
0
0
0
0
0
0
1 Female
0
0
0
0
0
0
0
2
Post
Pre
Post
3
Pre
4
Pre
Post
Pre
Post
3 Females
2 Females
1 Male
1 Male, 2
Females
1 male, 3
Females
1 Male, 2
Females
1 male, 2
0 Females
1 male, 4
Females
0
0
0
0 2 Females
1 Female
4. How do you feel
about buying clothes?
0
0
0
0 2 Females
1 Female
5. How does media
make you feel about
yourself?
0
0
0
0 1 Female
1 Female
2 Females
0 2 Females
2 Females
1 Female
1 Female
1 Female
7. How do you feel
when your family talks
about how they look? 1 Female
1 Female
2 Females
2 Females
2 Females
5
Post
3. How do you feel
about the way you
look?
6. How do you feel
when your friends talk
about how they look? 1 Female
Post
0
Responses
1
Pre
3 Females
Table 3. Pre- and Post-Intervention survey responses for Questions 1 and 2 (n=6).
Questions
Questions
Pre
B
1 Female
0 2 Females
2 Females
0
Table 4. Pre- and Post-Intervention Survey responses to Questions 3-7 (n=6).
1 Male
0 1 Male
1 Male
1 Male, 1
Female
Preadolescent Body Image and Body Mass Index
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Responses
Yes (0)
Questions
Pre
8. Do you feel that you
need to change the
way you look?
5 Females
9. Have you ever
dieted?
10. Have you ever
been told you need to
change your weight?
No (1)
Post
Pre
Post
2 Females
1 Male
1 Male, 3
Females
1 Male, 1
0 Female
1 Male, 5
Females
1 Male, 5
Females
1 Male, 3
Females
4 Females
0 2 Females
Table 5. Pre- and Post-Intervention Survey responses to Questions 8-10 (n=6).
Preadolescent Body Image and Body Mass Index
13
Number of Students Responding
Pre- and Post-Test Responses to "How do you feel
when your friends talk about how they look?"
2.5
2
1.5
Pre-Test
1
Post-Test
0.5
0
1
2
3
4
5
Pictorial Likert Scale Responses
Figure 3. Responses to the question 6 “How do you feel when your friends
talk about how they look?”
Number of Students Responding
Pre- and Post-Test Responses to "How do you feel
when your family talks about how they look?"
2.5
2
1.5
Pre-Test
1
Post-Test
0.5
0
1
2
3
4
5
Pictorial Likert Scale Responses
Figure 4. Responses to the question 7 “How do you feel when your family
talks about how they look?”
Preadolescent Body Image and Body Mass Index
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All participants reported a positive body image or total body image score at pre- and
post-test (Figure 5). The body image score increased in the post-test in four of the female
participants. In regards to total body image score, the male participant reported the highest score
of 28. Three of the female participants increased their total body image scores by three points
from pre-test to post-test, and one participant’s total body image score increased by six points
from pre-test to post-test. The lowest total body image score was 17 at pre-intervention, although
this score is reflective of positive body image.
When investigating body image discrepancy, participants in each BMI category reported
slight differences in desire to change their body figure (Question 2). Four of the six participants
believed they looked similar to a smaller figure at post-test versus pre-test. Although participants
had a total positive body image in questions 3-10, five of the six participants indicated measured
body image discrepancy. Participants reported lower body image discrepancy at post-test with
more participants either reporting they did not want to change the way that they looked or they
only slightly wanted to change the way they looked.
Preadolescent Body Image and Body Mass Index
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Figure 5. The difference in Body Image scores pre- and post-intervention
Discussion
Overall, there were no significant differences between body image and BMI percentile.
Researchers of previous studies among adolescents and young adults have found relationships
between BMI percentiles and body image2. Banitt and colleagues found that body image
discrepancy was positively related to BMI percentile2.
There also has been evidence of using interventions as a possible way to improve
perceived body image among participants. Neumark-Sztainer et al. studied longitudinal
associations between body satisfaction and health behaviors, determining that lower body image
can lead to higher risk of behaviors that could place adolescents at risk for weight gain16. It was
suggested in the study that interventions should strive to enhance body satisfaction and avoid
messages that could decrease body satisfaction. In another study, Neumark-Sztainer et al. found
that interventions aimed at the primary prevention of disordered eating and increasing knowledge
Preadolescent Body Image and Body Mass Index
16
of healthy attitudes had a modest effect on knowledge and attitude towards perceived body
image and body size acceptance17.
Many factors could have caused discrepancies in the data collected from this study. The
high total body image scores of the participants could reflect a very high body image, or there
could be evidence that the questions were fully understood and correctly answered.
With such a small study population, and the small number of nutritional lessons for the
intervention, we did not anticipate a large change from pre- to post-testing. However, during the
interventions there was high positive attitude during each of the lessons, the participants seemed
to have a good understanding of what it meant to adopt healthy habits, and the participants
encouraged future research and interventions through feedback of what they believed would be
successful in the future.
Further research is needed to determine factors that could influence the relationships
between BMI percentiles and body image. It is also recommended that future studies include
larger study populations, especially focusing on increasing male participation. Future studies
with a more representative sample of males and females could better aid in the investigation of
gender differences.
Although measures were taken to select and review questions and responses,
comprehension among this age group is challenging. One important factor to take into
consideration in future research would be to design and pilot test surveys among target
population groups. Research suggests that better understanding of socioenvironmental, personal
and behavioral characteristics in preadolescents can help guide interventions12, 28. Pilot test
surveys should aim at better understanding these factors, as well as helping preadolescents,
especially males, overcome social inhibitions of expressing feelings about body image8.
Preadolescent Body Image and Body Mass Index
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Conclusion
Though the population size in this study was small, the research findings can help inform
further studies on preadolescents and to improve interventions in primary and secondary
institutions. Past studies have considered interventions an important means to not only improve
body image, but to educate participants on how to live healthier lives9, 12, 16. The data in this
study can be amplified in larger studies and the nutrition education lessons can be used as models
to help inform the development of future interventions to encourage healthier living and positive
body image among children and adolescents.
Preadolescent Body Image and Body Mass Index
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