The Implications of Obesity on Self-Esteem of Adolescents
Christina Payne
B.S., 2014
Applied Research Project Paper
Submitted in Partial Fulfillment
Of the Requirements for the Degree of
Master in Public Health
Concordia University, Nebraska
May 2014
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Abstract
The prevalence of childhood obesity is an alarming trend across the United States. Obesity
affects seventeen percent of all children and adolescents in the United States, which is triple the
rate from one generation ago (CDC, 2013). Childhood obesity has negative consequences on
physical health, but what we do not realize is that it affects emotional health as well. It is not
known to what magnitude obesity contributes to self-esteem, but studies have proven that it can
have lasting effects. The main objective of this study is to show that as a child transitions from
childhood to adolescence, self-esteem will decrease if obesity levels remain the same. The
research also shows that lower education levels of both parents and child play a part in childhood
obesity. Although there may be some gaps in the research, determining how low self-esteem
affects a child on a psychological level was one of the goals. Administering baseline and followup questionnaires to the National Longitudinal Survey of Youth (NLSY) cohort allowed us to
answer the questions related to self-esteem, education, and psychological issues related to
childhood obesity. Biometric data was also collected on each participant at baseline and followup. The main research studies that were used remained current, dating from 2000 to 2011.
Research done by Gerrard et al, (2011), Hesketh et al (2004), Dempster et al (2008), Strauss
(2000), and Caterson et al (2006), proved that as the obesity levels increased or remained the
same, self-esteem levels decreased. Education levels also had a direct impact on childhood
obesity (Hesketh et al, (2003), and Gerrard et al, (2011), and Strauss (2000). Although some
conclusions were made regarding how low self-esteem impacted psychological issues, the
research had its limitations.
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Table of Contents
Acknowledgements………………………………………………………………………..i
Abstract…………………………………………………………………………………...ii
Table of Contents………………………………………………………………………...iii
List of Appendixes……………………………………………………………………….vii
Chapter 1: Introduction……………………………………………………………………1
Background………………………………………………………………………..2
Thesis Statement…………………………………………………………………..3
Purpose of Study…………………………………………………………………..3
Research Questions and Hypothesis………………………………………………4
Research Question One……………………………………………………4
Research Question Two…………………………………………………...4
Research Question Three………………………………………………….4
Theoretical Base…………………………………………………………………...5
Definition of Terms........................................................................................................5
Assumptions...................................................................................................................6
Limitations .....................................................................................................................6
Delimitations ..................................................................................................................7
Significance of the Study ...............................................................................................7
Summary ........................................................................................................................8
Chapter 2: Literature Review ...............................................................................................9
Introduction ....................................................................................................................9
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Advance Organizer ........................................................................................................9
Obesity and Self-Esteem………………………………………………………………10
Research Review…………………………………………………………………..12
Procedures…………………………………………………………………………12
Variables/Measurement Instruments……………………………………………..13
Data Analysis……………………………………………………………………..13
Results……………………………………………………………………………..14
Conclusions………………………………………………………………….……14
Education Level and Childhood Obesity……………………………………………..15
Purpose……………………………………………………………………………16
Setting……………………………………………………………………………..16
Risk Estimates and Procedures…………………………………………………..17
Variables/Measurement Instruments…………………………………………….17
Data Analysis……………………………………………………………………..17
Results……………………………………………………………………………..18
Limitations…………………………………………………………………………18
Conclusions……………………………………………………………….………18
Psychological Issues and Low Self-Esteem……………………………………………19
Purpose…………………………………………………………………………….20
Settings…………………………………………………………………………….20
Procedures…………………………………………………………………………20
Variables/Measurement Instruments……………………………………………..21
Data Analysis and Results………………………………………………………..21
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Limitations………………………………………………………………………21
Conclusion………………………………………………………………………22
Summary……………………………………………………………………………..22
Chapter 3
Methodology…………………………………………………………………244
Introduction…………………………………………………………………………244
Setting……………………………………………………………………………….24
Participants and Sampling………………………………………………………….25
Demographic Data………………………………………………………………….26
Measurement Instruments………………………………………………………….27
Data Collection, Measures and Analysis..…………………………………………29
Research Question One…………………………………………………………29
Research Question Two…………………………………………………………31
Research Question Three………………………………………………………..32
Protection of Human Participants…………………………………………………..33
Summary……………………………………………………………………………..33
Chapter 4 Results………………………………………………………………………..34
Introduction………………………………………………………………………….34
Demographic
Data……………………………………………………………………284
Research Question 1……………………………………………………………..35
Data Set One……………………………………………………………..36
Data Set Two…………………………………………………………….37
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Data Set Three……………………………………………………………38
Data Set Four……………………………………………………………..39
Summary………………………………………………………………...39
Research Question 2……………………………………………………………..40
Data Set One…………………………………………………………….40
Data Set Two…………………………………………………………….41
Data Set Three…………………………………………………………...41
Summary…………………………………………………………………42
Research Question 3……………………………………………………………..42
Data Set One……………………………………………………………..42
Data Set Two…………………………………………………………….43
Data Set Three…………………………………………………………...44
Summary…………………………………………………………………46
Chapter 4 Summary……………………………………………………………………..46
Chapter 5: Discussion, Conclusion, Recommendations………………………………..48
Introduction………………………………………………………………………….48
Interpretation of Findings……………………………………………………………49
Research Question 1……………………………………………………..49
Research Question 2…………………………………………………….50
Research Question 3…………………………………………………….50
Discussion……………………………………………………………………….51
Recommendations for Further Study…………………………………………..53
Conclusions……………………………………………………………………...54
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Summary…………………………………………………………………………………56
References………………………………………………………………………………..69
List of Appendixes
Appendix A: Child Health Questionnaire Parent Form (CHQ PF 50)……………….58
Appendix B: Mean and SD Scores for Domains of Self-Perception………………….60
Appendix C: Demographic Data at Enrollment and Follow-up………………………61
Appendix D: Sample Description Characteristic………………………………………63
Appendix E: Change in Global Self-Esteem……………………………………………64
Appendix F: Relative Risk of Low Perceived Domain Competency…………………..65
Appendix G: Factors Associated with Low Self-Esteem……………………………….66
Appendix H: Baseline and Follow-up Characteristics of Retained Cohort……………67
Appendix I: Percentage of Children with Low Perceived Self-Competency……………68
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Chapter 1: Introduction
Background
The prevalence of childhood obesity has become an alarming trend across the United
States. Obesity now affects seventeen percent of all children and adolescents in the United
States, which is triple the rate from one generation ago (CDC, 2013). Children (aged 2-19 years)
who test between the 85th and 95th percentile are considered overweight, and those above the 95th
percentile are classified obese (CDC, 2013). Environmental, cultural, and lifestyle preferences
are all part of the growing cause of obesity, caused by a caloric imbalance. The changes that
affect children’s calorie intake are the increased availability of energy-dense, high-calorie foods
and drink (Anderson & Butcher, 2006). A plethora of factors have also contributed to reduction
in calorie expenditure. Children have replaced outside activities with video games and
computers. Childhood obesity has negative consequences on physical health, but what is not
realized is that it affects emotional health as well. Although studies show that there is a direct
correlation between obesity and low self-esteem, some studies are not conclusive in
demonstrating the effects in children and adolescents (Strauss, 2000). Adolescents with lower
levels of self-esteem demonstrate significantly higher rates of sadness, loneliness, and
nervousness (Strauss, 2000). In turn, these adolescents have engaged in behaviors such as
smoking, drinking, and other high risk behaviors as self-esteem decreases. Low self-esteem is
associated with a number of modifiable risk factors (Gerrard et al, 2011). Obesity is one of these
factors that can be prevented and reversed.
Studies show that adolescents who are obese and have self-esteem issues grow up as
adults that are affected by low self-esteem (Mendelson & Romano-White, 1982). These findings
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still hold true; the problem is that if obesity has risen to over 30 percent, we have an increase in
self-esteem issues that have tripled over the past thirty years as well.
Self-esteem can be a reflection of one’s self-worth, as well as their belief system.
According to Gerrard et al, (2011), self-esteem is an important determinant of adolescent mental
health and development, and is associated with psychological, physical, and social consequences
that can affect the transition into adulthood. Once in adulthood, issues such as depression,
anxiety, suicide, eating disorders, violent behavior, early initiation into sexual activity, and
substance abuse are just a few of the health concerns that plague adults that have had low selfesteem (Gerrard et al, 2011).
A lack of education, poor lifestyle choices, lack of physical activity, and changing
trends of play, are all to blame for the increase in childhood obesity levels. Education should be
the key driver to childhood obesity prevention. Studies have shown that nutrition education and
physical activity are two primary components that can help reduce obesity in children (AkhtarDanesh et al, 2005). Secondary techniques are prevention of weight gains following weight loss
through proper nutrition and physical activity. Behavior modification for both children and
adults are key strategies to prevent further reoccurrences. As prevention strategies continue for
children, educating professionals was essential, so that when self-esteem issues do arise,
prevention measures can be practiced and carried out. Professionals are quick to prescribe
medication to mask feelings of depression or anxiety, both components of low self-esteem. The
ultimate goal is to take each child/adolescent through a natural process of prevention techniques
to minimize the risks of obesity and self-esteem that could follow them into adulthood. As
obesity levels decrease, self-esteem levels may also start to increase, ensuring a hopeful future
for our youth.
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Thesis Statement
During the transitions from childhood to adolescence (aged 2-19 years), self-esteem
will significantly decrease if obesity levels remain the same.
Purpose of the Study
The purpose of this study was to determine to what extent childhood obesity affects
self-esteem from childhood to adolescence (aged 2-19 years). Studies have shown that
childhood obesity represents one of the most pressing nutritional problems facing children in the
United States, but it is also known that few problems in childhood have a significant impact on
childhood emotional development as obesity (Must & Strauss, 1999). Adolescence is a critical
period for the development of body image and self-esteem. The need for this study was to see to
what extent obesity plays on self-esteem, and what can be done to reverse this problem.
According to Must & Strauss (1999), some obese children appear to have low self-esteem, but
the actual prevalence of this problem is controversial. The need to find out the correlation
between obesity and self-esteem is vital in preventing further psychological problems in
adolescents. Some studies may also show that education levels play a part on childhood obesity.
The goal was to determine if the above is true; and to what extent education levels play on
childhood obesity. Another factor that is not really known is to what extent low self-esteem will
have on a child mentally. Determining how low self-esteem will affect a child on the
psychological level, helps fill the gaps in the research.
The studies that were utilized are population-based correlational studies, crosssectional studies, and prospective cohort studies based off of the design carried out by Gerrard et
al, (2011), Hesketh et al (2004), Dempster et al (2008), Strauss (2000), and Caterson et al (2006).
Each study tested at least 2000 (1000 children will act as the control group) children ages 5-10 at
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baseline and follow-up three to four years later. Children who tested at or above the 85th
percentile for BMI-for-age according to the CDC growth charts (CDC, 2013) were used as the
experimental group and those below the 85th percentile were used as the control group. Each
child in the study took a questionnaire at baseline and then again in three to four years. The
questionnaires contained questions in which the participant ranked each question on a one to five
scale. The results were compiled after each test. The expected outcomes of these tests predicted
that as the participant’s age increased, their self-esteem levels decreased as long as their BMIfor-age status stayed above the 85th percentile. The questionnaire, along with the other
demographic data, showed that low education levels in parents and children, played a part in
higher obesity levels in children.
Research Questions and Hypotheses
Research Question 1.
During the transition from childhood to adolescence (aged 2-19 years), does selfesteem significantly decrease if obesity levels remain the same?
Null Hypothesis: The transitions from childhood to adolescence (aged 2-19
years), does not significantly decrease self-esteem if obesity levels remain the same?
Hypothesis: The transitions from childhood to adolescence (aged 2-19 years),
does significantly decrease self-esteem if obesity levels remain the same?
Research Question 2.
Does education level play a part in childhood obesity?
Null Hypothesis: There is no significant difference in education level and
childhood obesity?
Hypothesis: There is a significant difference between education level and
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childhood obesity?
Research Question 3.
What psychological issues does low self-esteem cause in obese children (aged 2-19
years)?
Null Hypothesis: Obese children (aged 2-19 years) do not have significant
psychological issues due to low self-esteem?
Hypothesis: Obese children (aged 2-19 years) do have significant psychological
issues due to low self-esteem?
Theoretical Base
This study is based on qualitative literature and grounded theory. Specifically, it
relates to behavioral theory and ecological theory. Ecological theory for childhood obesity is
seen in Baur et al, (2004), where the author’s provide insight into the risk related to childhood
obesity in the ecological realm, i.e. behavioral, environmental, and social factors. In Egger et al,
(1999), the author’s user a broader framework of environmental known as “obeseogenicity,” in
which determinants of obesity are reinforcing the ecological model. In French et al, (2012), the
author’s present a very comprehensive literature review based in behavior theory, which
demonstrates the psychological consequences of childhood obesity and low self-esteem.
Definition of Terms
Body Mass Index (BMI): a measure of body fat based on height and weight that
applies to adult men and women (NIH, 2014).
Obesity: defined as BMI at or above the 95th percentile for children of the same age and
sex (CDC, 2013).
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Overweight: defined as a BMI at or above the 85th percentile and lower than the 95th
percentile for children of the same age and sex. (CDC, 2013).
Assumptions
The assumptions made during this study are that during the transitions from childhood
to adolescence (aged 2-19 years), self-esteem levels decreased if obesity remains the same.
Strauss (1999), also indicated that low self-esteem is more prevalent in females of adolescent age
compared to their male counterparts. Also according to Strauss (1999), Hesketh et al (2004),
Caterson et al (2006), Dempster et al (2008), and Gerrard et al (2011), as age increases, low selfesteem also increases in obese children (ages 2-19 years). It is also assumed that lower
education levels will cause higher obesity levels in children, causing more psychological issues
as the child matures.
Limitations
Although studies show that obese children appear to have low self-esteem, the actual
prevalence is controversial (Must & Strauss, 1999). Most self-esteem issues arise from ridicule
from peers; describing obese children as lazy, lying, cheating, sloppy, dirty, ugly, and stupid
(Caskey, nd). As these subjects are ridiculed by their peers, it is hard to know how these subjects
truly feel about themselves. For example, the child may think they are “normal” and not see
themselves as overweight until their peers continue to ridicule them. They will base their
perception not on how they think, but how their peers may perceive them.
Another limitation in our study is the questionnaires that were used. Although the
same questionnaire at baseline and follow-up were used, perception and how our subjects alter
our results. The control group may alter the results if they change status from the 85th percentile
for height and weight. Obesity has been shown to decrease self-esteem, but other factors may
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also contribute as well. Maintaining external validity within the two groups has been a difficult
task. The fact that this study had one thousand obese children and one thousand who are
controls, have helped this study maintain validity.
Delimitations
In the following studies, approximately 2000 children ages 5-10 years old also
participated in the study. One thousand children who were considered obese by the CDC’s
Growth Chart (CDC, 2013), and the other 1000 children were used as a control group. Each
child had a parental consent prior to the study. All subjects, both parent and child, were
informed of how the study was to be conducted as well as the duration of the study. The
transition of childhood into adolescence occurs between the ages of 10-12 (Eccles, 1999). If the
participants are tested at ages 9 and 10 (baseline for childhood), they transition into adolescence
by age 13. The baseline participants may not have exactly understood what was being measured,
but by the time they took the questionnaire in year four, they had a pretty good concept of what
was being asked of them.
Significance of the Study
The significance of this study was to determine how obesity affects self-esteem in
children and adolescents. Childhood obesity may have detrimental consequences on self-esteem,
but it is still not fully known to what extent the social and emotional effects do to a child. This
study filled the gaps of our unknown variables. The extent or severity of obesity on self-esteem
is measured in this study, as well as the psychological issues involved with low self-esteem.
Once it was determined how much obesity affects self-esteem, the information was taken and
applied at a professional level to help decrease this problem. The studies took approximately
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five years to complete; from the baseline to the follow-up questionnaire. Filling the gaps in the
research was another goal for this study.
Summary
As childhood obesity continues to rise, so does the prevalence of low self-esteem.
Low self-esteem has been shown to cause feelings of loneliness, depression, and anxiety. These
tendencies may also lead to risky behaviors such as consuming alcohol and smoking. Studies
show that the prevalence of childhood obesity cause low self-esteem in adolescents, so
questionnaires helped determine the severity of this problem (Strauss, (1999), Hesketh et al
(2004), Caterson et al (2006), Dempster et al (2008), and Gerrard et al (2011)). Two-thousand
children ages 9 and 10 were chosen to participate in this study. One group of 1000 children was
the research group, and the remaining were used as the controls. The study continued for four
years and each participant filled out a questionnaire at baseline and then again at the four-year
follow-up. BMI levels were also measured at baseline and follow-up. At the end of four years,
the results were studied and at that time it can be determined if the study was successful in
validating our hypotheses. There were limitations to this study, but the researchers have
accounted for this. The results show a direct correlation between obesity and low self-esteem.
Lower education levels and socioeconomic status also show a direct correlation with rising
obesity levels. Low self-esteem was also thought to cause psychological issues in children; the
goal was to determine to what extent. If the results showed a positive correlation, it can be
suggested that obesity preventative programs be implemented. The study will continue to look at
relevant literature to justify the findings in this particular research.
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Chapter 2: Literature Review
Introduction
Childhood obesity has increased drastically in the last decade, and continues to plague
children (aged 2-19 years). Childhood obesity has been proven to have a negative impact on
health as well as self-esteem. As Strauss (2000) mentioned in his study, “the social and
emotional effects of decreased self-esteem in obese children (aged 2-19 years) are unknown.
Although he states that the results of self-esteem are unknown, it has been proven that obesity
and self-esteem have a direct correlation. Strauss (2000) is not the only one who has been able
to find the direct correlation between childhood obesity and self-esteem. Studies such as
Hesketh et al, (2004), Caterson et al (2006), Dempster et al (2008), and Gerrard et al (2011),
have also shown that there is a direct link between the two variables and many researchers have
taken different approaches to find the correlation.
Advance Organizer
The literature review addressed the three questions related to the correlation of obesity
and low self-esteem. There are characteristics associated with childhood obesity that affect
children more than others. For example, we ask ourselves, “Which characteristics play a larger
role on obesity and self-esteem?” During the transition from childhood to adolescence (aged 219 years), “Does self-esteem significantly decrease if obesity levels remain the same? At what
age does a child (aged 2-19 years) begin to correlate obesity and self-esteem? What role does
education levels play on childhood obesity? What psychological issues does low self-esteem
cause in obese children (aged 2-19 years)?” These are all questions that needed to be addressed.
The following section will describe the process of obtaining the literature needed to answer the
questions.
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Once the areas were identified, the process of obtaining literature reviews could begin.
It is important to use information that was reputable and peer reviewed. The first step was to use
the search engines that provided us with scholarly articles for our research. For example, Google
Scholar is a great tool to start basic research. Literature found at this site is usually a scholarly
review, so it can be assumed it is reputable. Using other search engines and using the “advanced
search” option was a great way to get journal articles. The Concordia University online library
as well as Wiley Library Online, were also a great source for journal articles.
Childhood obesity is a problem that can be potentially prevented or reversed at a young
age, so there were three areas that need to be addressed. In the first section, there was a
discussion on how the transition from childhood to adolescence had an effect on self-esteem if
obesity remains the same. If it does have an effect, at what ages does the correlation of the two
start? The second section covered the evidence that education levels play a part in childhood
obesity and self-esteem. The final section focused on the psychological issues associated with
low self-esteem and obesity in children (aged 2-19 years).
Obesity and Self-Esteem
Many researchers have spent numerous hours trying to find a correlation between
childhood obesity and self-esteem. Research indicates that studies have been documented prior
to the 1970’s. There have been questions as to what the relationship between obesity and selfesteem actually is, but much of the research indicates that there is a negative correlation between
the two variables; as childhood obesity continues to rise, self-esteem continues to decrease
(Strauss,( 2000), Demster et al, (2008), Gerrard et al, (2011), and Hesketh et al, (2004)). The
question that needed to be answered is what age do obese children (aged 2-19 years) start to
realize that their body image has decreased and they start to feel the effects of low self-esteem?
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According to Strauss (2000), Hesketh et al, (2004), Caterson et al, (2006), and Gerrard et al
(2011), childhood obesity does cause a child to have low self-esteem compared to their
counterparts who are not obese. In a study by Dempster et al., (2008), the aim was to examine
the relationship between obesity and self-esteem in children in relation to specific domains of
self-perception. The results showed that overweight and obese children had reduced social
acceptance, which placed a negative effect on self-esteem levels. Strauss (2000) suggested in an
independent study, “There is no doubt that obesity is an undesirable state of existence for a child.
It is even more undesirable for an adolescent, for who even mild degrees of overweight may act
as a damaging barrier in a society obsessed with slimness.” His statement was given after he
designed a study that specifically tested obesity to self-esteem, as well as the age of onset of low
self-esteem due to obesity. A more recent study suggests that obese children not only had lower
self-esteem, but lower perceived athletic competence, physical appearance, and global self-worth
than their normal weight peers (Caterson et al, 2006). This study also mentioned that the results
found in obese children aged 13 and 14 years, had a significantly higher degree of low selfesteem. From their baseline questionnaires at ages 9 and 10 years, the questionnaire indicated
that as a child enters adolescence, perception changes. Over the 4-year period, childhood obesity
was directly associated with decreased levels of self-esteem (P< .05). Hesketh et al, (2004), also
carried out a prospective cohort study in elementary schools in which he measured BMI and selfesteem in 1997 and 2000. The results of his study determined that overweight/obese children
(elementary aged) had lower median self-esteem scores than their non-overweight counterparts.
Taking into account baseline self-esteem (ages 5-10 years), he found that higher BMI predicted
lower self-esteem scores after the follow-up (P=.008). He concluded that the data showed an
increasingly strong association between lower self-esteem and higher body mass for elementary
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school students from the baseline (Hesketh et al, 2004). Students (ages 5-10 years) had a lower
baseline self-esteem than they did three years later (ages 8-13 years). Taking both studies into an
account, the age that a child recognizes body image and self-esteem according the above studies
is between the ages of 10-14 years old.
Research Review
Most studies that were examined were carried out in a school system or used the National
Longitudinal Study of Youth (NLSY) cohort. The school system enables researchers to
determine the approximate age that children will start to focus on how they look and determine
self-esteem levels. Prior to any research done on the children, parental consent was gathered for
liability reasons. The baseline tests were done in children (ages 5-10 years old) and follow-up
data was collected 3-4 years later, at ages 9-14 years. Demographic data was collected in all
subjects regardless of what type of baseline self-esteem test was administered. Strauss’s (2000)
self-esteem was measured using the Self-Perception Profile for Children. Most studies had a test
that was similar to his baseline measures. Each study has evolved over the years and eventually
was expanded to provide assessments of social, emotional, and cognitive development of the
children who were in each cohort. One study in particular, used three questions to assess selfesteem by looking at global self-worth and physical appearance (Gerrard et al, 2011).
Procedures
Self-esteem was measured using the Self-Perception Profile for Children in most of the
studies found. The Self-Perception Profile for Children (SPPC) was administered at home by
trained bilingual interviewers as seen in these studies. Heights and weights were also taken by
the in-home interviewers using a portable scale and tape measure. The same procedure was used
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for each child; measurements taken at baseline, two years, three years, and again at four years
depending on the study (Strauss, 2000).
Variables/Measurement Instruments
In each study, there were at least three of the same variables measured at baseline.
Strauss’ participants had their height taken by a tape measure and weight was done by a scale.
The students were also given questionnaires to measure the baseline self-esteem. In Hesketh et
al, (2004), the height and weight were measured by trained field workers. Height was measured
by the Invicta portable rigid stadiometer, and weight was measured by the Tanita model 1597
digital scale. In Strauss’ study, demographic data was collected and the questionnaire was given
by a trained interpreter. The questionnaire and measurements were given at baseline and at the
four year follow-up. In the other study the same tools were used to measure variables, but the
questionnaire was parent-reported at baseline and then again in three years. The questionnaire
for the second study was the Child Health Questionnaire (CHQ PF50). In each study, the results
were repeated at least twice throughout the trial. Each study used the questionnaires to
determine the age that body image became evident to these children, and it was carefully
monitored each year of the study.
Data Analysis
All statistics in each study represented an equal sample of black and white children that
were preadolescent. In Strauss’s study, baseline measurements were taken at ages 9 and 10
years. In other studies, the mean age of baseline testing was 11.8 years (Caterson et al, (2006),
Hesketh et al, (2004), Gerrard et al, (2011), and Dempster et al, (2008)). The data from Hispanic
females and males were not used in certain analysis because of the small number of obese
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subjects in these two categories. Once baseline data was collected in the children (ages 8-12
years), follow-up testing determined how children ranked themselves and their self-esteem
levels. Low self-esteem scores were those that fell below the 15th percentile for baseline
(Caterson et al, 2006).
Results
The results of the first study did not see any significant differences between the scores of
the 9 and 10 year old obese children compared to their non-obese counterparts (Strauss, 2000).
However, as these children matured over the four year period, obese Hispanic females and obese
white females had a significant decrease in self-esteem, while a mild decrease in self-esteem was
also seen in obese boys compared to their non-obese counterparts over the four-year period
(Caterson et al, (2006), Hesketh et al, (2004), Gerrard et al, (2011), and Dempster et al, (2008)).
The result from this study concluded that as one reached 13 and 14 years, self-esteem
significantly decreased for those who were classified as obese compared to their non-obese
counterparts. Strauss (2000) also concluded that obese children with low levels of self-esteem
were associated with increased rates of sadness, loneliness, and anxiety. The results indicate that
as one moves from childhood into adolescence, the self-esteem levels tend to decrease if obesity
increases or remains the same.
Conclusions
There are several conclusions that can be made when looking at the specific studies
tailored to finding the correlation between childhood obesity, self-esteem, and the age that a
child can recognize how they feel about body image. Studies done by Strauss (2000), Hesketh et
al, (2004), Caterson et al, (2006), Dempster et al, (2008), and Gerrard et al, (2011), have proven
that there is a direct correlation between obesity and low self-esteem, but have also been able to
14
determine at what age these children recognize self-image. In Strauss’ study, obese Hispanic and
white females exhibited low self-esteem into early adolescence, which was between ages 11-14
years. Those who had lower self-esteem also showed signs of sadness, loneliness, and anxiety.
In the study by Hesketh et al, (2004), it can be concluded that there was a strong association
between low self-esteem and higher BMI levels in elementary school children after age 10 years.
This information may indicate that prevention and management strategies need to be
implemented to minimize the impact on self-esteem between the ages of 11-14 years. In a study
by Dempster et al, (2008), the aim was to examine the relationship between obesity and selfesteem in children in relation to specific domains of self-perception. The results showed that
overweight and obese children had reduced social acceptance, which placed a negative effect on
self-esteem levels.
Education Level and Childhood Obesity
Most childhood obesity issues arise without the child or parents knowing the direct risks
and consequences of what this disease can do to their child in the future. As the correlation
between obesity and self-esteem continue to increase into adolescence, studies are proving that
prevention and management strategies need to be implemented. According to Must & Strauss
(1999), complications of childhood obesity do not become apparent for decades. Obesity has
severe metabolic consequences that can have lasting effects into adulthood. As the health
problems continue into adolescence, so does the discrimination, teasing, and victimization of
these children. The direct problem with this situation is that most times the parents may be to
blame for their child’s problem because they are either obese themselves, or do not know how to
either prevent or “cure” their child’s problem. According to a study done by Maffeis et al,
(1998), and Knight & Strauss (1999), the parents’ obesity and a lack of education about the
15
disease is a main risk factor for obesity in children. Not only does obesity hurt a child
physically, but there are many emotional implications as well.
Purpose
The purpose of educating the public about obesity is the key to decreasing the epidemic
of this disease in the United States. Researchers may have difficulty distinguishing a correlation
between childhood obesity and self-esteem in their research. They have difficulty because
although they know there is a direct correlation, they do not know the extent to which obesity has
on self-esteem levels as many researchers such as Must &Strauss, (1999), Hesketh et al, (2003),
and Gerrard et al, (2011) have proven. Studies have shown that obesity in children not only
causes many health concerns, but it also affects self-esteem. Low self-esteem can lead to many
other psychological issues that can be compounded into adulthood. Depression, anxiety, and a
variety of other issues become more prevalent as self-esteem issues become more severe.
According to Strauss (2000), as self-esteem levels decrease, risky behaviors in
children/adolescents have a tendency to increase. As these numbers continue to rise, programs
will need to be implemented to reverse the trends.
Setting
These studies were designed to look at the short-termed risks associated with childhood
and adolescent obesity and educate the public about the consequences associated with this
disease. It was also to determine how a parent’s and child’s education level correlated to obesity
and self-esteem. The goal was to determine the social and economic consequences of childhood
obesity so professionals know how to help reverse this problem and start education programs.
Most of the information was based upon samples from pediatric specialty clinics and reported
through this project (Must & Strauss, 1999).
16
Risk Estimates and Procedures
The procedures of collecting the data on childhood obesity were observed and reported
through specialty clinics that mimic the risks observed if these subjects were in a populationbased study (Must & Strauss, 1999). No direct intervention techniques were used in the sample
population. Although most risk estimates were taken from small studies, they show a substantial
burden that childhood obesity can play on a child (aged 2-19 years).
Variables/Measurement Instruments
Landmark studies that date back to the 1960’s show that most obese children are
measured or ranked by other children as lazy, lying, cheating, sloppy, dirty, ugly, and stupid.
Children (aged 2-19 years) are also ranked as the least desired friends (Dornbusch, 1961).
Although these studies determined the short-term risks associated to childhood obesity, the focus
was on the social burdens associated with this disease. Educating about the outcomes of
childhood obesity were determined, and correlating the variables used to describe obesity, also
showed a decrease in self-esteem issues among children (aged 2-19 years).
Data Analysis
Although these studies tried to find the correlation between education and obesity levels,
the goal was also to educate about the risks and consequences of childhood obesity, and even
show the correlation to self-esteem issues. There was a gap in determining how education levels
fit into the equation. Data from the National Longitudinal Survey of Youth (NLSY) was
analyzed, but the data was inclusive in determining the consequences at the child/adolescent
level. It determined the consequences on youth (aged 16-24 years), and not children (aged 2-19
years). Education levels of parents also had a direct correlation on childhood obesity in children
(ages 2-19 years).
17
Results
Discrimination against obese adolescents resulted in low self-esteem, low confidence,
and may also contribute to low academic performance (Must & Strauss, 1999). Other studies
have also documented low rates of academic performance in overweight adolescents, causing
lower acceptance rates to universities, compared to their non-obese counterparts. This study also
mentioned that Dietz et al (1993), analyzed data from NLSY and concluded that women who
were initially obese (>95th percentile in BMI), completed less schooling, had lower incomes, and
had a higher rate of poverty. These are all factors that can be linked to a lack of education and
self-esteem levels.
Limitations
There were several gaps and limitations to the main study that was used for education
purposes. First, it was assumed that education about childhood obesity would be the topic of
discussion in this review. Secondly, although there was a lot of information about the health
implications of obesity, education levels of the participants were not discussed in detail, just
briefly mentioned. Thirdly, the sources used throughout some of the reviews were outdated,
even though the article was current. This could have been in part due to social stigmas regarding
poverty and obesity levels.
Conclusions
These studies determined the immediate, intermediate, and long-term consequences on
childhood obesity. Most consequences were directly related to health issues, but there was a
component that was associated with social and economic consequences of childhood obesity.
Education levels played a part in childhood obesity, primarily a lack of knowing what the
consequences of obesity are. Children (aged 2-19 years) who are obese are described as lazy,
18
lying, cheating, sloppy, dirty, ugly, and stupid (Must & Strauss, 1999). This stigma eventually
leads to other factors such as isolation, loneliness, and a lack of self-esteem. Middle childhood is
a crucial period for body image and self-esteem. Burt & Stunkard (1967) also suggested that as
women who become obese as children were likely to have low self-esteem and body image into
adulthood. As these subjects reach adulthood, the same studies show that women in particular,
have less education, lower paying jobs, and fall into poverty compared to their non-obese
counterparts (Dietz et al, 1993). All these variables are also factors that contribute to their
child’s obesity problem.
Psychological Issues and Low Self-esteem
Earlier studies also showed a direct correlation between obesity and low self-esteem
among children (aged 2-19 years). For example, Braet et al, (1997) found a correlation between
obesity and depression/anxiety states. He compared obese children from clinical and nonclinical settings with normal weight children and found that although self-esteem was low in
both groups, increased depression and anxiety was found in only the obese group. Must &
Strauss (1999) stated that if rates continue to rise, childhood obesity is likely to “challenge
worldwide public health.” He also indicated that although some obese children appear to have
low self-esteem, the actual prevalence of this problem is controversial. Studies that date back to
the 1970’s and 1980’s indicate that self-esteem and obesity among children have had a direct
correlation. Studies by Allon (1979), Sallade (1973), and Forehand et al, (1985), indicated low
levels of self-esteem in obese children as a group. They indicated that low self-esteem is not a
characteristic of obese minorities, but differences in age, race, and socioeconomic status may
have accounted for the differences in findings. Depression, anxiety, and a variety of other issues
become more prevalent as self-esteem issues become more severe. According to Strauss (2000),
19
as self-esteem levels decrease, risky behaviors in children/adolescents have a tendency to
increase.
Purpose
The purpose of this review was to examine the psychological effects that low selfesteem had on childhood obesity. Studies show that children with decreasing levels of selfesteem demonstrate significantly higher rates of sadness, loneliness, and nervousness and are
more likely to engage in high-risk behaviors such as smoking and consuming alcohol (Strauss,
2000).
Settings
Studies showed that the most widespread consequences of childhood obesity were
psychological (Dietz, 2013). Obese children (ages 2-19 years) are targets of discrimination from
their peers and society. As they mature, the effects of discrimination became more culturebound and insidious. Psychological issues can become more prevalent and can have lasting
effects. Overweight children are often thought of as lazy, lying, stupid, sloppy, dirty, ugly and
stupid (Must & Strauss, 1999). Children ranging in ages from 6-10 years associate obesity as
negative and they are less likely to have a lot of friends. All these factors have led to
discrimination in the obese child, potentially causing psychological issues as they age.
Procedures
In approximately seventy-five percent of the studies, children of the National
Longitudinal Survey of Youth (NLSY) were used to examine how obesity affects a child. In
each of the studies, the mother of each participant was also examined. This allowed researchers
to correlate variables and other indicators as to why her child may or may not be obese. The
NLSY cohort was followed for many years.
20
Variables/Measurements
Variables such as BMI, number of years of advanced education, family income, marriage,
and family origin were also incorporated into each study. The majority of the studies showed
that education levels were lower and poverty levels were higher as BMI levels increased.
Comparing the obese women of the study to their non-obese counterparts indicate that
psychological issues due to obesity that arise in adolescence, may lead to the same issues in
adulthood and directly affecting their children. The data suggests that obesity may be the worst
socioeconomic handicap that women who were obese adolescents can suffer (Dietz, 2013).
Data Analysis and Results
As data suggested above, obesity may be the worst socioeconomic handicap that women
who were obese as adolescents can suffer (Dietz, 2013). The cycle of obesity has shown to cycle
from generation to generation, especially in women. Psychosocial consequences represent the
most prevalent morbidity associated with obesity and may even be the source of obesity. Studies
suggest that early identification of psychological/psychosocial issues in obese adolescents may
be the key for prevention and treatment.
Limitations
There were limitations to the study in regards to what psychological issues play a role in
the lives of obese children. Studies have shown that obese children (ages 5-10 years) may start
to recognize the difference between obesity and normal weight, but young children do not have a
negative self-image at this age (Kaplan & Wadden, 1986), and (Sallade, 1973). As shown in
other studies, obese adolescents (ages 11-14 years) develop a negative self-image that follows
them into adulthood. The gap in research exists between the transition from childhood to
adolescence. It has already been determined that this transition happens from ages 11-14 years.
21
One explanation for the discrepancy is that self-image is derived from parental messages in
young children and from the child’s culture as they reach adolescence (Dietz, 2013).
Conclusion
The studies in this literature review have shown that childhood obesity can have limited
psychological effects as a child transitions into adolescence. Low self-esteem in adolescence is
associated with increased rates of sadness, loneliness, and nervousness, which may also cause
other problems such as smoking and consuming alcohol. The psychological/psychosocial
problems that are present in obese children/adolescence may be a reflection of maternal
socioeconomic status rather than obesity, but this is a gap in the literature that has yet to be
determined. It has been determined by many researchers that obesity levels in children does
have a direct correlation on low self-esteem, which in turn may lead to
psychological/psychosocial issues in adolescence, and further into adulthood. The conclusion
still has some limitations, which we will discuss in future chapters.
Summary
Nearly one in five children (ages 2-19 years) are considered obese. It is known that
childhood obesity causes a variety of health problems, but there are also specific studies that are
used to determine what childhood obesity does to self-esteem levels. It was determined that the
age in which a child correlates self-esteem and obesity is between the transition from childhood
to adolescence (ages 11-14 years). Education is also thought to play a huge role in child obesity
levels as seen in our research. A lack of education, socioeconomic status, and income levels
particularly of the mother, are thought to cause higher levels of obesity in their children. Finally,
low self-esteem levels also cause psychological/psychosocial issues in obese children. Low self-
22
esteem causes feelings of loneliness, sadness, and anxiety in children and adolescence. Children
who are obese are described as lazy, lying, cheating, sloppy, dirty, ugly, and stupid; only adding
to the psychological issues these children deal with on a daily basis. As Bruche wrote in 1975,
“There is no doubt that obesity is an undesirable state of existence for a child. It is even more
undesirable for an adolescent, for whom even mild degrees of overweight may act as a damaging
barrier in a society obsessed with slimness.” It has been proven that obesity has psychological
ramifications on adolescents; the next section will examine the methods used to prove the
correlation between childhood obesity, self-esteem, and psychological issues.
23
Chapter 3 Methodology
Introduction
In Chapter 1, three questions were conceived in relation to childhood obesity and selfesteem. The research questions drove us to finding the correlation between self-esteem and
childhood obesity. In this chapter explained the research methods and designs that were used to
conduct the study. I chose nine research articles that spaned from 1999 to 2011. The more
recent articles were used as a primary source of information, but I will also refer to the older
articles dated 1999-2006. The studies have shown how the prevalence of childhood obesity had
an impact on self-esteem over the past fifteen years.
Research Design
The research studies that were used in this compilation of the literature were qualitative.
The use of a baseline questionnaire, followed by a post questionnaire at the end of the three to
four-year periods was used to analyze the effect of childhood obesity on self-esteem levels. In
some of the studies reviewed, participants were evaluated yearly to track the progression of the
study.
Comprehensive demographic data was also available in each cohort. Self-esteem was
measured using the Self-Perception Profile for Children in each cohort. For each child who was
not able to fill out their own questionnaire, the parent-reported Child Health Questionnaire (CHQ
PF50) was used in conjunction to the study. At the completion of the studies, results were
analyzed using descriptive and inferential statistics.
Setting
These studies took place in children born to women who were members of the National
Longitudinal Survey of Youth (NLSY). Random samples of children who were in the first four
24
years of elementary school (ages 5-10 years) were tested at baseline (Hesketh et al, 2004), as
well as children aged 8-9 years drawn from disadvantaged and advantaged schools (Dempster et
al, 2009). The pre and post testing was conducted in-home or in the school setting. BMI was
calculated for height and weight, and then transferred to z-scores. The baseline questionnaire
was either Harter Self-Perception Profile for Children or the parent reported Child Health
Questionnaire (CHQ PF50). An example of the CHQ PF50 can be seen in appendix A. The
Harter Self-Perception Profile for Children is so long, it was not included in this report. All
races and genders were included in the study to prevent bias. Additional data was also collected
concerning emotional well-being, smoking and alcohol consumption through self-examination.
As the children transitioned into adolescence (ages 11-14 years), they were tested again for
complete analysis.
Participants and Sampling
For the study research, it began with a literature search using Google Scholar. I found
that I was able to find all my scholarly articles using this method. When using Google Scholar, I
was able to find all peer-reviewed journal articles that were published between the years 19992011. Typically we would look for articles that were more current (2006-present), but I wanted
to find the trend in low self-esteem due to obesity in children and adolescents. Looking back at
the last fifteen years of research and how the methods have changed to capture the data has been
interesting, due to the fact it really has not changed very much.
In Strauss (2000), Hesketh et al, (2004), Dempster et al, (2008), Caterson et al, (2006),
and Gerrard et al, (2011), the sampling procedure used by the researcher was random sampling.
In Strauss (2000) and Hesketh et al, (2004), the participants were born to women who were
members of the National Longitudinal Survey of Youth (NLSY). Comprehensive data was also
25
available on each participant in this study. In Dempster et al, (2008), Caterson et al, (2006), and
Gerrard et al, (2011), participants belonged to the same cohorts in the elementary school setting.
School cohorts were easy to use due to each participant’s availability. These students were also
followed over the course of three to four years. Comprehensive/demographic data was also
available on each participant in both groups. This information was used to determine whether or
not race, gender, socioeconomic status (SES), and other factors contribute to self-esteem levels.
Once each participant was selected, the children had their BMI measurement taken and then split
into the research and control groups. Purposive sampling was used in these studies because the
researcher selected individuals who were representative of higher BMI levels. Children who
scored above the 85th percentile for BMI were used as the research group and those below the
85th percentile were used as the controls (Strauss (2000) and Hesketh et al (2004)). Our goal was
to follow the research group over the course of the 3-4 year time period to see if data changed
from baseline to follow-up. Using the control group allowed us to also measure self-esteem and
compare it to those who measured above the 85th percentile for BMI.
Demographic Data
The number of participants in the study averaged 1,200 male and female children from
the NLSY cohort. NLSY consists of a national sample of young adults that included a sample of
Hispanics, blacks, and poor whites. The weighted sample of children is nationally representative
of children born to 17 to 28 year old mothers. Data on their children were used in this study at
baseline, two years, and at the completion of the study (Strauss, 2000). One of the questions
addressed was at what age does a child start to recognize self-esteem? It was determined that as
a child moves into adolescence, self-esteem levels become more apparent. At the start of the
study children 5-10 years old were given the Self-Perception Profile for Children or Child Health
26
Questionnaire to determine self-esteem levels. As these same children transitioned into
adolescence (ages 11-14 years), they were tested at two years and then again at four years, which
was the completion of the study. The ages of the participants at the completion of the study was
9-14 years old (Strauss, 2000) and (Hesketh et al, 2004). The goal was to determine self-esteem
as one transitioned into adolescence, which was completed by the four year study. By taking this
information, we could correlate the ages to the change in self-esteem levels and determine at
what age children start to notice their self-image/perception. This allowed us to answer the
question as to what age self-esteem levels became more noticeable. Determining the transition
from childhood into adolescence (11-14 years) was a good determinant of our hypothesis.
Measurement Instruments
This study utilized research from peer-reviewed publications from available literature.
As such, no instruments were used. In Caterson et al, (2006), Hesketh et al, (2004), Strauss
(2000), Gerrard et al, (2011), and Dempster et al, (2008), the materials used were very minimal.
For example, BMI levels were determined using height and weight measurements according to
the Centers for Disease Control and Prevention 2000 Growth Chart (CDC, 2012). In all studies,
each participant was given a questionnaire. In Hesketh, et al, (2004), the Child Health
Questionnaire was used to determine baseline global self-esteem and self perception. Strauss
(2000), Caterson et al, (2006), Dempster et al, (2008), Gerrard et al, (2011), all used the Harter
Self-Perception Profile for Children to determine components of self-esteem. Each questionnaire
tested the same components; self-esteem, health, interaction with others, and how the parents
thought the child perceived themselves. BMI levels were determined by taking height and
weight measured by trained field workers. This technique proved to beneficial so all
measurements could be kept consistent. Once the questionnaire and BMI data was determined,
27
the research could be analyzed to see what methods worked better so we could pick out the best
research studies to use.
Height was measured by the Invicta portable rigid stadiometer, and weight was measured
by the Tanita model 1597 digital scale (Hesketh et al, 2004). Demographic data was collected
and the questionnaire was given by a trained interpreter. The questionnaire and measurements
were given three times throughout the studies. For children who were unable to answer the
questionnaire, parent-reported answers were used at baseline. Another questionnaire that was
used in the study was the Child Health Questionnaire (CHQ PF50)-see appendix A. Only one
study (Hesketh el al., (2004), used this form of the questionnaire, and the results were very
similar to the data used in the Harter Self-Perception Profile.
At the completion of each study, results were taken from the Self-Perception Profile for
Children and the Child Health Questionnaire. Analysis was done on the change between
baseline and post questionnaire testing. BMI levels were also taken at the completion of the test
because in the four-year period, BMI levels decreased in some of the participants. Low selfesteem levels were defined as those below the 15th percentile on the self-esteem subscale. Using
the charts and data tables provided in each study allowed us to visually look at the data and
compare the results side-by-side. We will look at these variables further in Chapter 4.
Data Collection, Measures, and Analysis
The data collected for this research is a compilation of the available literature related to
the following research questions from Chapter 1.
Research Question 1
During the transition from childhood to adolescence (aged 2-19 years), does selfesteem significantly decrease if obesity levels remain the same?
28
Null Hypothesis: The transitions from childhood to adolescence (aged 2-19
years), does not significantly decrease self-esteem if obesity levels remain the same?
Hypothesis: The transitions from childhood to adolescence (aged 2-19 years),
does significantly decrease self-esteem if obesity levels remain the same?
Data collection for the first research question took four years to answer. The baseline
questionnaires were taken between the years of 5-10 years old. Out of all the studies used for the
research, none have found that the baseline questionnaire indicated low self-esteem levels were
in place even if a child was obese. Determining baseline values only, was not a good indicator of
self-esteem levels. There must be a baseline and follow-up to analyze to see changes in the data.
When the questionnaire was taken again at two and four years post baseline, the data found was
very different than the baseline, especially for the children who had elevated BMI levels.
After accounting for baseline self-esteem, higher baseline BMI z-scores predicted poorer
self-esteem at follow-up (Hesketh et al, 2004). Over the 3 year follow-up period, 102 (8.8%) of
the non-overweight children became overweight or obese, while 46 of the 220 (20.9%)
overweight/obese children moved into the normal weight category (Hesketh et al, 2004). We can
take this data that is given and visually see that in each study, self-esteem levels have either
decreased or stayed the same. Dempster et al (2009), showed a similar correlation between
socioeconomic factors and BMI levels through MANOVA variables. The data showed that
obesity had an effect on social acceptance/self-esteem for those only in the obese category. As
seen in Table 1 in appendix B, (Dempster et al, 2009), obese children that were from the more
deprived areas showed lower scores (mean=2.5, SD=.7) compared to the less deprived children
(mean=3.2, SD=.6, t=4.03, P<.001). Looking at these variables, we can conclude that obesity
levels have a direct correlation on low self-esteem and self-perception. Being able to look at the
29
variety of different research variables allows us to determine how obesity levels play a part in
self-esteem levels.
Research Question 2
Does education level play a part in childhood obesity?
Null Hypothesis: There is no significant difference in education level and
childhood obesity?
Hypothesis: There is a significant difference between education level and
childhood obesity?
The data collection process to answer this question will come from the baseline
questionnaire, but we will also focus on a population-based correlational phone survey done on
6522 adolescents aged 12-16 years (Gerrard et al, 2011). The interesting data in this study
showed the parent-reported education levels. Just by looking at the data in Appendix D, we can
conclude that parent education levels can have an effect on obesity and self-esteem levels.
Multivariate logistic regression was used to examine a variety of different variables, but
the one that was focused on was school performance, socioeconomic status and parent income
levels as mentioned above.
Other analysis done was qualitative, so we did not have numeric
values associated with this question. Recent research also suggested that low self-esteem in
adolescence may also be a reason why they have fewer years of post-secondary education,
greater likelihood of joblessness and financial difficulties, and poorer mental health and higher
rates of criminal behavior (Gerrard et al, 2011). A lack of education in parents of obese children
is also to blame for a child’s obesity rates (Akhtar-Danesh et al, 2005). From the data above, we
can conclude that the hypothesis is true; education level does affect obesity in children.
Research Question 3
30
What psychological issues does low self-esteem cause in obese children (aged 2-19
years)?
Null Hypothesis: Obese children (aged 2-19 years) do not have significant
psychological issues due to low self-esteem?
Hypothesis: Obese children (aged 2-19 years) do have significant psychological
issues due to low self-esteem?
Data collection to determine whether or not obese children had greater psychological
issues compared to those who were not obese proved to be a bit more complex. In the studies
by Caterson et al (2006), and Dempster et al., (2008), we looked at a few components in from the
questionnaire that dealt with scholastic and athletic competence, social acceptance, physical
appearance, and global self-worth to determine what psychological issues may come from low
levels in these areas. The data does not come out and tell us that childhood obesity and low selfesteem cause psychological issues; we have to conclude this from the data that is given. We
know that quantifying risks of psychological distress among obese adolescence is becoming
increasingly important, but we do not know to what extent. In an article by Connolly (2013), it
is suggested that humans have two psychological cravings. Typically parents meet the first set of
needs; love, affection, warmth, and caring. In some cases, as obesity levels tend to rise, children
are ridiculed, even described as lazy, lying, cheating, sloppy, dirty, ugly, and stupid (Must &
Strauss, 1999). This negative feedback can have detrimental effects on a child and lower selfesteem levels to a dangerously low level. Obese children with lower levels of self-esteem
demonstrate significantly higher rates of sadness, loneliness, and nervousness and are more
likely to engage in high-risk behaviors such as smoking and consuming alcohol (Strauss, 2000).
We can continue to look at other studies, but each one tells the same story; as obesity rates
31
increase, self-esteem decreases and children suffer more psychological issues because of this
correlation. Just from the data we have thus far, we can only determine a small portion of what
psychological issues arise in an obese child. The data is not as conclusive as it is with answering
the rest of our questions. I do feel there is a gap here, and this area is one we can expand on for
future studies.
Protection of Human Participants
For this research, there are no human subjects used in this study. The BMI measurements
and demographic information is obtained using research studies, or metadata, which is fully deidentified.
Summary
The prevalence of childhood obesity is an alarming trend across the United States and
affects seventeen percent of all children and adolescents in the United States (CDC, 2013). In
most of the studies, participants from the National Longitudinal Study of Youth were used as the
study participants. Baseline questionnaires were used to determine the effects of childhood
obesity on self-esteem and how they correlated with psychological issues. IRB’s were used in
conjunction with the questionnaires. Other data was taken from specialty clinics in which parent
consent forms were signed prior to treatment. Demographic data was taken from every subject.
Materials and measurement instruments were very minimal, only consisting of a stadiometer and
a basic digital scale to measure BMI levels. Testing each child in the home or school setting by
trained professionals kept the results valid and reliable. Each procedure was the same with each
participant; either using the Self-Perception Profile for children or the Child Health
Questionnaire reported by the parents. As mentioned above, each child had BMI measurements
taken at baseline, two years and again at the completion of the test, three to four years post
32
baseline. The data analysis was addressed to answer the three questions we posed in chapter one.
By analyzing the data, we were able to answer the questions and accept our hypothesis in each
area. The above sections will allow the replication of this research for future study. Further
studies will allow this gap to eventually be filled. For the remainder of this qualitative study, it is
pertinent to report the results of these studies, and apply what has been learned from the data
collection. We will see these results presented in Chapter Four.
33
Chapter 4 Results
Introduction
This chapter will address the analysis and results related to the correlation between
childhood obesity, self-esteem, and education levels. The goal was to determine to what extent
childhood obesity has on self-esteem levels and what psychological issues arise from low selfesteem. We also looked at how education levels of the parents and child play on obesity levels.
The first step in our research study was to analyze the data taken from the parent reported Child
Health Questionnaire, and the Harter Self-Perception Study for Children (Appendix A). The
main information gathered from the questionnaire was the information that pertained to selfesteem, emotional parental impact, mental health status, and general behavior. Gathering the
baseline data helped determine the changes over the four year study. The next set of information
analyzed was the BMI levels of each child. The BMI values were then changed to z-scores to
predict self-esteem levels. Demographic data was also submitted, so this information was used
to help determine the correlation between the variables.
Most studies measured excellent test-retest reliability between the two questionnaires.
Correlation coefficients were used to determine the validity between the questionnaires. The p
value was also determined in these studies. Mean scores and confidence intervals, percentages,
and relative risks for perceived competency and global self-worth according to gender and
weight group also played a role in answering the questions we posed in Chapter 1.
Demographic Data
The National Longitudinal Survey of Youth (NLSY) was the main cohort of children
used in the studies. The NLSY is a federally funded study administered by the US Department
34
of Labor. Its mission has shifted to provide a comprehensive assessment of factors that influence
social, emotional, and cognitive development of children born to mothers enrolled in the NLSY
(Strauss, 2000). This cohort will play an integral part in answering the questions from chapter 1,
because comprehensive demographic data including race and family income allowed for analysis
of the economic influences and education levels associated with childhood self-esteem. In
addition to these factors, longitudinal sampling allowed for determination of emotional effects of
low self-esteem on obese children (Strauss, 2000). Prior to the questionnaires and BMI testing,
demographic data was taken to determine gender, race, and family income. Global self-worth,
scholastic self-worth, and BMI levels were also taken at baseline. Appendix C shows the
percentages of each gender, race, family income (% above median), and obesity levels according
to Strauss (2000), at baseline and again at follow-up. As seen from the data and pie charts, there
are about equal percentages of each gender, race, family income (%), and obesity (%), from
baseline to follow-up. These numbers are ideal because bias can be prevented with the baseline
percentages being similar to the follow-up data. We used this data to determine the answer to the
first question. The hypothesis is accepted, so understanding how childhood obesity affects selfesteem levels is determined. Appendix D also includes a chart indicating the sample
characteristics that aided in answering the questions as well as the number of each in their
perspective category (Gerrard et al, 2010). According to appendix C and D data, all populations
are represented in the study.
Research Question 1
During the transition from childhood to adolescence (aged 2-19 years), does selfesteem significantly decrease if obesity levels remain the same?
Null Hypothesis: The transitions from childhood to adolescence (aged 2-19
35
years), does not significantly decrease self-esteem if obesity levels remain the same?
Hypothesis: The transitions from childhood to adolescence (aged 2-19 years),
does significantly decrease self-esteem if obesity levels remain the same?
Data Set One
To determine if low self-esteem levels are a result of obesity levels of children and
adolescents, one must answer the first question. Baseline data taken from the Harter SelfPerception Profile for Children were taken and these values were put into table 1 in Appendix E.
The full questionnaire can be seen at the website in Appendix A. The follow-up self-esteem
levels were also taken after four years and put into table 2 in Appendix E (Strauss, 2000). As a
result of the four-year longitudinal study, self-esteem levels of obese boys, obese Hispanic girls,
and obese white girls had a significantly lower self-esteem by 13 and 14 years of age.
The tables in Appendix E helped determine the age range where self-esteem levels
become prevalent, as well as how it changed as obesity levels remained the same. To prove the
hypothesis regarding obesity levels decrease self-esteem levels, the data in Appendix E will
demonstrate values to help accept the hypothesis. According to Strauss (2000), as a group, obese
males showed a mild decrease in self-esteem levels over the four-year period (-.8), which was
the equivalent of 14 percent. In females aged 13 to 14 years old, 34% of obese white girls and
37% of Hispanic girls had lower self-esteem esteem compared to their non-obese counterparts
(8% and 9%) respectively. At follow-up, levels of self-esteem were lower in obese Hispanic
compared to non-obese Hispanic girls (P<.05), and obese white girls compared to their nonobese counterparts (P<.001). Looking at the data in the entire NLSY population, childhood
obesity was associated with decreased levels of self-esteem over the 4-year period (P<.05). We
36
know that the baseline age for the questionnaire was 5-10 years of age, therefore the ending ages
of follow-up would be 9-15 years old. We can conclude from our data that the age range where
self-esteem becomes more prevalent is between 10-15 years old. According to the data from
Strauss (2000), the alternative hypothesis may be accepted that as obesity levels increase or
remain the same, self-esteem levels will decrease. The null hypothesis is rejected. Additional
data sets are reviewed below to collaborate the results.
Data Set Two
Another study that proved childhood obesity affects self-esteem levels in adolescents was
research from Caterson et al (2006). Relative risk values were determined with a 95%
Confidence Interval (CI) on variables with underweight, normal weight, overweight, and obese
children. Global self-worth and social acceptance were the two variables to study in this data set.
Appendix F showed the table derived from Caterson et al (2006), as described in terms of
relative risks and confidence intervals (CI). Relative risk is the rate of a poor outcome of our
intervention group divided by the rate of poor outcome in the control group. The relative risk is
1 (normal weight group) when the intervention has no effect, and below 1 when it has a positive
outcome. It will be greater than 1 when it does harm (National Center for Biotechnology
Information, 2008). According to the table in appendix F, obese boys and girls were between 2
and 4 times more likely than their normal weight counterparts to report low global self-worth
according to the RR values. From the data, the relative risk (RR) for social acceptance for obese
boys and girls are 1.29 and 2.11 respectively. The rates for boys and girls global self-worth are
2.52 and 4.12 respectively. Looking at social acceptance, underweight boys have a relative risk
of 1.03, while females are 1.36. For overweight boys in the global self-worth category, the
relative risk is 1.69 and females were 2.37 respectively. Therefore, boys are more than 1.5 times
37
more likely to have low global self-worth, while girls are almost twice that value to have low
global self-worth due to obesity. In the social acceptance category for boys and girls, the values
increased from (1.03 to 1.29 and 1.36 to 2.11) respectively (Caterson et al, 2006). In the global
self-worth category, female values increased from.42 to 4.12 and boys were .89 to 2.52
(Caterson et al, 2006). The increase in relative risk for all four categories indicate that as obesity
levels increased, global self-worth and social acceptance levels decreased also. The data derived
from Caterson et al, (2006) on relative risks allow the alternative hypothesis to be accepted. As
obesity levels increase or remain the same, self-esteem levels will decrease. The null hypothesis
was rejected. As obesity levels increase (underweight to obese) global self-worth/esteem and
social acceptance decrease. Additional data sets are reviewed below to collaborate the results.
Data Set Three
Appendix G lists characteristics associated with low self-esteem in bivariate (chisquared) analysis (Gerrard et al, 2011). The percent of teens with the definition of low selfesteem was greater as the age increased from 12 to 16 years old. For example, at age 12, low
self-esteem was 15.3%, age 14 was 19.4%, and age 16 was 25.1%. Differences were found by
race, with proportionally fewer black teens having low self-esteem (17.2%), compared with
whites (19.5%), and Hispanics (24.1%), having a higher rate of low self-esteem (Gerrard et al,
2011). For weight status, normal weight factors indicated only 18% low self-esteem, but as the
category changed to obese, low self-esteem levels increased to almost double at 30.4%. Taking
all data into consideration, the alternative hypothesis was accepted. As weight status increases
(normal weight to obese), self esteem levels decrease. The null hypothesis is rejected.
Additional data sets are reviewed below to collaborate the results.
38
Data Set Four
The self-esteem scores were calculated from the data on the Child Health Questionnaire
(CHQ PF 50) as seen in Appendix A. Appendix H shows self-esteem and BMI scores at both
baseline and follow-up. Low self-esteem scores were those that fell below the 15th percentile (a
score of <66.7) for both baseline and follow-up for self-esteem (Hesketh et al, 2004). According
to the table (Appendix H), the number of children that moved from normal weight to the
overweight or obese category was substantial. At baseline, the number of children who were
obese was 174, and it increased to 227 children at follow-up. This is nearly a 30 percent increase
in the four year span. The self-esteem category did not show any significant changes compared
to other data that we have looked at. For example, low self-esteem values (<15th percentile) had
a mean score of 195 at baseline and 210 at follow-up, thus only increasing by a mean score of
15, from baseline to follow-up. This indicated only a 1 percent increase, which was not
significant enough to prove our hypothesis, as obesity levels increase, self-esteem levels
decrease. According to the study by Hesketh et al (2004), the alternative and null hypothesis
cannot be accepted or rejected due to data that does not show enough of a variance between
variables.
Summary
In order to answer the first question in this study, data was taken from Strauss (2000),
Hesketh et al (2004), Gerrard et al (2011), and Caterson et al (2006). In each study, the data
showed that as obesity levels increased or remained the same, self-esteem levels decreased. The
information in each data set proved the alternative hypothesis is accepted in each study except
39
for one. In Hesketh et al (2004), the data showed a small percentage in difference between
variables the alternative and null hypothesis could not be accepted or rejected at this time.
Research Question 2
Does education level play a part in childhood obesity?
Null Hypothesis: There is no significant difference in education level and
childhood obesity?
Hypothesis: There is a significant difference between education level and
childhood obesity?
Data Set One
Another key factor that helped determine how obesity affects children is through
education levels. Some research indicated the education level of the parent, while others
determined the scholastic competence of the child. The data in this section helped determine if
the hypothesis is correct. Appendix B (Dempster et al., 2008), showed scholastic competence
against BMI levels. As seen from the BMI column, normal mean scores were (2.81), compared
to obese mean scores (2.78). The decrease in mean values indicated that education level does
play a part in obesity levels, which in turn can cause low self-esteem levels in adolescents.
Appendix B also shows socioeconomic status (SES) against scholastic competence. The SES
data also indicated that those who were most deprived (2.74), also had a lower mean value that
the least deprived (2.85). This data from Dempster et al, (2008) supports the alternative
hypothesis that lower education levels and obesity have a direct correlation. With these findings,
the null hypothesis can be rejected. Additional data sets were reviewed below to collaborate the
results.
40
Data Set Two
Appendix F also showed the correlation between obesity and education levels. The
relative risk (RR) of scholastic competence and four levels of BMI for females and males are
shown in table 2 (Caterson et al, 2006). According to table 2, the RR values in the male category
of scholastic competence showed that as weight increased (underweight, .87), the RR values
determining self-esteem levels increased (obese, 1.13). As the RR value increased above 1, the
correlation between the two variables increased. The prevalence of low self-esteem levels due to
scholastic competence increased as weight levels increased. In the female category, the results
were similar. Scholastic competence for the underweight category (.94) was lower than the
obese category (1.29). The higher the RR value is, the higher the prevalence of low self-esteem
according to education levels (scholastic competence). The data from Caterson et al (2006),
allows the alternative hypothesis to be accepted. Low education levels are correlated to
childhood obesity. This data allows the null hypothesis to be rejected, due to RR values that
were greater than 1. Additional data sets were reviewed below to collaborate these results.
Data Set Three
Also seen from the table in Appendix G, students who had excellent school performance
showed higher self-esteem levels (14.9% low self-esteem), than those who had below average
school performance (26.7% low self-esteem). The values from the normal self-esteem
percentages were (85.1% and 73.3% normal self-esteem) from the excellent to below average
school performance respectively. The data from Gerrard et al, (2011), supported the hypothesis
that there was a significant difference between education level and childhood obesity. However,
this is a compilation of the research data, so one could not draw this conclusion from a single
41
research study. Therefore, additional research recommendations will be discussed in Chapter 5
for what research design is needed to empirically answer this research question and reject or
accept the null hypothesis.
Summary
In order to accept the alternative hypothesis that education levels and obesity were
correlated, studies from Gerrard et al (2011), Caterson et al (2006), and Dempster et al (2008),
determined that the alternative hypothesis was true. Although each study was used as a
determining factor, the data from Gerrard et al (2011) was not significant enough to accept or
reject the alternative or null hypothesis.
Research Question 3
What psychological issues does low self-esteem cause in obese children (aged 2-19
years)?
Null Hypothesis: Obese children (aged 2-19 years) do not have significant
psychological issues due to low self-esteem?
Hypothesis: Obese children (aged 2-19 years) do have significant psychological
issues due to low self-esteem?
Data Set One
There was limited data that determined how obesity and self-esteem levels affect a child
psychologically. This is where there is a gap in the research. Questions 1 and 2 have been
answered through the extensive research, but question 3 has gaps that need to be filled before
accepting the hypothesis. The data found does not directly indicate psychological levels, but
other indicators that would have an effect on a child’s mental state. Strauss (2000) mentioned
that obese children who have low levels of self-esteem have significantly increased rates of
42
sadness, loneliness, and nervousness which may lead to risky behaviors such as smoking and
consuming alcohol. There is not enough information from Strauss (2000) to determine the
answer to the third question. In the study by Dempster et al, (2008), data in Appendix B,
allowed some conclusions to be made as to how obesity affects a child on the psychological
level. Self-perception domains could have been used to determine how a child thinks mentally.
The data set in Appendix B shows that socioeconomic status (SES) had an effect on scores for
social acceptance, but only for the children who were overweight or obese. According to
Dempster et al, (2008), overweight/obese more deprived children had significantly lower scores
(mean=2.5, SD=.7) than their less deprived counterparts (mean=3.2, SD=.6, P<.001). The mean
scores were lower in every category except behavioral conduct for BMI scores in the
overweight/obese category. The overall mean scores for every category for the most deprived in
the SES category also showed that scores were lower. Although it was not known how low selfesteem levels directly affect a child psychologically, it is known that decreasing rates of low selfesteem, including social acceptance, competence, global self-worth, and physical appearance,
may cause feelings of sadness, loneliness, and nervousness. The latter may be indicators that
psychological issues may arise in the future, but the data does not strongly suggest this at this
time. Further research will have to be accomplished in order to accept or reject the null and
alternative hypothesis. Additional data sets were reviewed below to collaborate the results.
Data Set Two
Table 1 in Appendix F also showed some variables that may affect psychological issues
in adolescents. Social acceptance and global self-worth were compared to the weight categories
in the table derived from Caterson et al, (2006). In males, the relative risk value of social
43
acceptance increased as the obesity rate increased (1.03, 1.24, to 1.29 respectively). In females,
the RR value was higher in underweight children (1.36), but continued to increase as one entered
the obese category (1.57 to 2.11). The obese category had over a double correlation value.
Global self-worth also showed some of the same trends as social acceptance moved in to the
obese category. In males, the global self-worth value started out at (.89) for the underweight
category, and continued to increase as they reached the obese category (2.52). In females, the
trend was the same. Underweight females (.42) showed a direct correlation to negative selfworth as one reached the obese category (4.12). Females showed an almost double increase in
RR in each category. Although this data does not directly mention psychological issues, Strauss
(2000) has mentioned that decreased levels of self-esteem increased feelings of sadness,
loneliness, and nervousness, which may lead to risky behaviors. Conclusions from this data
suggested that obesity does have some effect on psychological issues, although not directly
mentioned. Some of the data from Strauss (2000) allowed the alternative hypothesis to be
accepted, but there was a gap in this portion of the research to be able to determine if a child was
affected psychologically. Additional data sets are reviewed below to collaborate the results.
Data Set Three
In Appendix I, data was also used from Caterson et al, (2006), to determine the
percentage of children with low perceived self-competency and global self-worth in the different
weight categories. Social acceptance and behavioral conduct helped answer question three.
Psychological issues were not directly scored, but looking at other values that may cause
psychological problems may help understand these issues. In both the males and females, social
acceptance scores increased as the weight category increased. According to Caterson et al,
44
(2006), male scores ranged from underweight (8.2%) to overweight (9.8%) and then finally
obese (10.2%). Females also showed the increase in low perceived social acceptance as obesity
levels increased. According to Caterson et al (2006), underweight females were (11.6%),
overweight (13.5%), and obese (18.2%). Females had an 8% higher score for social acceptance
than their male counterparts in the same category. This might be expected looking at previous
data and how obesity affects the female population. There is a stigma associated with obesity
and social rejection that is attached to body fat shapes (Caterson et al, 2006). This would
indicate that obesity levels affected social acceptance in females at a higher level than males,
possibly causing more psychological related issues in females, especially as she matured into
adulthood. Interestingly, the study suggests that in some cultures fatness is a sign of health and
children from these families do not distinguish such factors as inhibitors to social rejection and
behavioral conduct compared to their normal weight peers. Self-esteem, psychological and
social outcomes have shown to have no impact on obese children from these cultures (Caterson
et al, 2006). Behavioral conduct had no direct correlation to obesity levels in either males or
females. Looking at the underweight, overweight, and obese categories for males (5.5%, 8.3%,
6.3%), and females (4.1%, 5.2%, 3.0%), showed very little change in the different weight
categories, indicating that obesity has little affect on how a child acts. There was also a gap in
this data, although the research studies that are being performed are getting closer to accepting
the alternative hypothesis that obesity and self-esteem may affect a child on the psychological
level. Although not completely determined, the null hypothesis is getting closer to being
rejected. Further studies will need to be conducted. Recommendations for future research
studies to address this research question will be discussed in Chapter 5.
45
Summary
Caterson et al, (2006), Strauss (2000), and Dempster et al, (2008), conducted studies to
determine how childhood obesity and low self-esteem levels affect a child on the psychological
level. In each study, it was hard to determine what psychological issues played a part with each
child. Factors such as social acceptance, behavioral conduct, feelings of sadness and loneliness
were all characteristics that may have contributed to psychological well-being. In each study, the
data was not complete enough to fully accept or reject the null and alternative hypothesis. The
research from Strauss (2000) was closest in accepting the alternative hypothesis, but more
research needs to be done before the alternative hypothesis can be accepted.
Chapter 4 Summary
Overall, the research studies that were chosen for this issue were mostly adequate in
finding the answers asked in Chapter 1. In question one, we wanted to determine how obesity
affected self-esteem. This question was answered through a variety of different research studies.
Strauss (2000), Hesketh et al, (2004), Caterson et al, (2006), Gerrard et al, (2011), and Dempster
et al, (2008), provided the information used, there was a direct correlation between obesity levels
and low self-esteem. It was found that as one goes from childhood to adolescence (period
between baseline test and follow-up) that low self-esteem levels become more prevalent as
obesity stays the same. To determine the answer to this question, relative risk, bivariate analysis,
and responses from the two questionnaires given at baseline were used. With all the data given,
the hypothesis can be accepted that as obesity rates increase or remain the same, self-esteem
decreases.
46
To answer question two, studies by Gerrard et al, (2011), Dempster et al, (2008), and
Caterson et al, (2006) were used. These studies showed that parents who have lower education
levels have a higher rate of obese children. This was also prevalent in the studies done with the
NLSY cohort. Data suggests that the NLSY cohort has been followed for many years so the data
is readily available to answer our questions. Studies also done by Dempster et al, (2008) showed
there is a correlation between obesity and education levels. Scholastic competence and
socioeconomic status were also correlated with obesity levels and each study showed that as the
scholastic competence and socioeconomic status for the most deprived decreased, higher obesity
levels played an integral part in this. It can also be concluded from these studies that obesity
does play an integral role in education levels.
Research question three had some gaps that needed further research. This research did
not allow us to know how low self-esteem levels affect a child/adolescent on the psychological
level. Further research will have to be done to answer this question in more depth.
Characteristics such as social acceptance, competence, global self-worth, and physical
appearance, can help to better understand how these play in to the psychological issues that arise
in children and adolescents. One limitation to the research was defining what factors affected a
child’s psychological level. Characteristics shown in this section were similar to that for
questions one and two. As obesity levels increased, characteristics such as acceptance, global
self-worth, and competence levels tend to decrease. As these characteristics decrease, they must
have an effect on psychological issues, but it is not known how much they have an effect.
Rewording the question in future studies may help determine what components make up the
psychological aspect of a child so it can be better determined what the long-term effect is. The
discussion can continue as we move into Chapter 5, the discussion of the thesis.
47
Chapter 5: Discussion, Conclusions, and Recommendations
Introduction
Children that are considered obese typically have lower self-esteem than their non-obese
counterparts. Children tested at baseline have low self-esteem levels, but the prevalence of low
self-esteem was higher when tested again at the 3-4 year follow-up (Strauss, (2000), Caterson et
al (2006), Dempster et al, (2008), Gerrard et al (2011), and Hesketh et al, (2004). One factor that
was linked to this epidemic was the education level of the parents and the scholastic competence
of the child. Studies show that lower education levels are linked to higher levels of obesity,
causing low self-esteem (Gerrard et al, (2011), Dempster et al, (2008). This challenge has led
researchers into looking at ways to reduce this problem as well as what future implications lie in
store for these children.
Research has tried to identify what role obesity and low self-esteem levels have on a
child/adolescent’s psychological state. The research has found that low levels of self-esteem
cause increased rates of sadness, loneliness, and nervousness causing these adolescents to
participate in risky behaviors (Strauss, 2000). The research does have its limitations, so there are
recommendations for future study in this area.
The purpose of this qualitative study was to determine how obesity affects the selfesteem level of a child, as well as how education plays a part in childhood obesity. As the
children mature into adolescence, the research should indicate how these issues play a part in the
psychological problems of a child. Although there may be gaps in the data, providing discussion
and interpretation to the research will provide insight to the growing problem of childhood
obesity.
48
Interpretation of Findings
Research Question One
In regards to the first question that was asked in chapter one, self-esteem levels were
determined using baseline questionnaires from the Harter Self-Perception Profile for Children
and the Child Health Questionnaire. Each child had their height and weight taken to determine
BMI levels. Children tested at baseline (ages 5-10 years) showed decreased levels of self-esteem
when tested again at follow-up (ages 9-14 years) while obesity levels increased or stayed the
same (Strauss, (2000), Caterson et al, (2006), Dempster et al, (2008), Gerrard et al, (2011), and
Hesketh et al, (2004)). These questionnaires were designed to measure values such as age, race,
gender, socioeconomic status, global self-esteem, education levels, and behavioral issues. Data
from each questionnaire was used to asses children that were obese compared to those who were
normal weight according to BMI height/weight charts (CDC, 2013). The interpretation of this
data would indicate that obesity not only harms a child on the physical level, but also
emotionally and mentally. Obesity affects health by increasing the risk for cardiovascular
disease, diabetes, and certain types of cancer (CDC, 2013). These studies have proven that
obesity in children and adolescents cause major self-esteem issues as well. According to
prospective data from the Dunedin Multidisciplinary Health and Development Study cohort, the
researchers found that adolescents with low self-esteem had poorer mental and physical health,
worse economic prospects, and higher levels of criminal behavior during adulthood compared to
adolescents with high self-esteem (Caspi et al, 2006). Obesity levels are interpreted through selfesteem levels because of the long-term implications it can cause. The study suggests that low
self-esteem during adolescence is a predictor of negative real-world consequences into
adulthood.
49
Research Question 2
Education level of both the parent and child play a role in childhood obesity. Studies
have proven that a lack of education in the parents result in higher obesity levels in children
(Dempster et al, 2008; Caterson et al, 2006; Gerrard et al, 2011). Factors such as no post
secondary or limited education in the parents, scholastic competence and school performance in
children contribute to this growing problem of obesity. As the studies have proven, childhood
obesity levels also contribute to low self-esteem levels. The interpretation of this hypothesis
builds upon question one. If education plays a part in childhood obesity and childhood obesity
can cause low self-esteem, we ask ourselves what component is the one that needs to be
addressed? The fact is that many factors contribute to childhood obesity; education levels are
just one component that have shown to be a contributor. A lack of education is not a precursor to
obesity, but the reason behind this hypothesis is that lower education levels may mean that
people just do not know how obesity affects their health and they may not be able to afford
healthy foods. This interpretation would need further research to indicate its validity, but may
just be part of the reasoning behind this hypothesis.
Research Question 3
According to Strauss (2000), decreasing levels of self-esteem due to obesity significantly
increased the rates of sadness, loneliness, and nervousness. These three components may have a
direct effect on a child’s psychological state, but the research would support this on a small scale
only. Defining characteristics that may have a part in the psychological level is one limitation
that needs to be addressed. Although other factors such as social acceptance, physical
50
appearance, and behavioral conduct have been linked to a child’s psychological state, what
happens to a child who has low self-esteem is not addressed directly (Dempster et al, 2008).
Strauss (2000) also proves that feelings of sadness, loneliness, and nervousness increases as selfesteem decreases, but this is where the study stops. No further data was collected as to what
happens when the child got older and low self-esteem issues remained. Data from Strauss (2000)
and Dempster et al, (2008), can be interpreted many different ways. Low self-esteem levels
cause feelings of sadness and loneliness, but are these factors enough to cause depression and
other issues? The interpretation would indicate that any feeling of sadness, loneliness, low social
acceptance, and issues with behavior would be severe enough to reverse the trend of childhood
obesity.
Discussion
Although the studies used determined the correlation between obesity and self-esteem
levels, there were several limitations to this study. The first limitation was finding how low selfesteem levels affected a child on a psychological level. The first mistake was that it was not
specified as to what components of “psychology” were actually going to be tested. Defining
components that contributed to psychological issues should have been the first step to this
portion of the study. This particular study measured global self-worth, scholastic competence,
behavior, social acceptance, and socioeconomic status, but it was never determined if any of
these factors play a role in how a child is affected on a psychological level. Conclusions from
the data can be made to say that all the above components are characteristics of a child’s
psychology, but the definitions were not laid out prior to the study. Therefore, there are
limitations regarding the definition of what psychological issues really mean.
51
Another minor limitation in the research was how education level is classified. There
would be arguments against saying that just because someone only has two years of postsecondary education means they are less educated than someone with a four-year college degree.
The research never defines how many years a person has to go to school to become “educated.”
Studies show that lower education levels play a large part in childhood obesity. Is this because
they do not know what makes them obese, or is it because they have a lower paying job and
cannot afford the more expensive healthy food? These are both limitations to the data. The data
allows the question to be answered, but the steps as to how they got there are very vague.
These studies used the National Longitudinal Study of Youth cohort to conduct the
research. By using this cohort solely, the results are limited to children born of mother’s ages 17
to 28 years old. Looking at the lower end of the age group of mothers, it would be assumed that
they have not had any college. The hypothesis states that education plays a part in childhood
obesity. If these mothers are still of high school age, it may be assumed that their children are at
a higher risk of obesity, causing low self-esteem. Low self-esteem may be caused by a single
parent household, poverty, or living with other family members. Also, many women are having
children at an older age, so this age group is completely limited and cut out of the study.
The last limitation was finding enough current research to accept the hypotheses. Instead
of using research that used just one form of baseline questionnaire, studies that used the Harter
Self-Perception questionnaire and the Child Health questionnaire were used to determine selfesteem as well as other factors. Each questionnaire was similar, but it would have made the
results easier to decipher if one was used solely. One test measured the follow-up data at three
years, and the other at four. This test also was so lengthy that it took much longer to find the
needed results. The above limitations affect the internal validity of the results-the lack of
52
defining key terms, finding variables associated with them, and keeping the years of the study
consistent are all variables that will affect the study negatively. As other researchers look into
this topic, changes can be made prior to collecting data to increase the validity in the research.
Recommendations for Further Study
Based on the results of the study, there are several recommendations that need to be made
for further research. First of all, some of the limitations may have been decreased if definitions
were set prior to each study. The questionnaires should have been limited in some areas and
asked more questions pertaining directly to family life. Although obesity levels and low selfesteem are correlated, there may be some family dynamics that play a part in decreasing selfesteem levels during the testing period. These issues could pose limitations, but they are unable
to be directly correlated because of the nature of this study. Another recommendation for further
study is using participants that are not just a part of the National Longitudinal Study of Youth
(NLSY). As mentioned in previous sections, the NLSY is a federally funded study administered
by the US Department of Labor that has expanded its mission to provide a comprehensive
assessment of factors that influence social, emotional, and cognitive development of children
(Strauss, 2000). Although this cohort provides an equal sample of race and sex, it would be a
strong recommendation to include other cohorts that are not a part of the NLSY. Opening up the
research to all school aged children from ages 5 to 14 years would yield a wider population with
a variety of results. If this particular study was duplicated, the recommendations would be that
definitions would be set prior to the study. It would also be open for all school ages children
ages 5-14 years old. The same questionnaire would also be used, specifically the Harter SelfPerception Study. It is not expected to get completely different results, just a wider array of
results that can be used to accept or reject the hypothesis.
53
Conclusion
As the studies have shown, the prevalence of childhood obesity is an alarming trend across
the United States. Obesity has affected seventeen percent of all children and adolescents in the
United States, which is triple the rate from one generation ago (CDC, 2013). Childhood obesity
has negative consequences on physical health, and it also affects emotional health as well. The
objective of this study was to show the correlation between childhood obesity and three other
factors; self-esteem, education level, and psychological issues. Many scholarly articles were
used in this study, but there were five in particular; (Caterson et al, (2006), Dempster et al,
(2008), Gerrard et al, (2011), and Hesketh et al, (2004), Strauss (2000)). Each study helped
answer the questions and either accept or reject the hypotheses that were formulated.
The purpose of the first study was to show that as a child transitions from childhood to
adolescence, self-esteem will decrease if obesity levels remain the same. The methods used to
determine the above factors came from children of mothers of the National Longitudinal Survey
of Youth (NLSY) cohort, who were given baseline questionnaires and had their BMI’s taken.
Decreasing levels of self-esteem contribute to significantly higher rates of sadness, loneliness,
and nervousness. These conditions also contributed to high risk behaviors such as consuming
alcohol and smoking (Strauss, 2000). Other studies have shown a significance decrease in selfesteem levels for obese children tested at baseline and then at follow-up (Caterson et al, (2006),
Dempster et al, (2008), Gerrard et al, (2011), and Hesketh et al, (2004)). These results are shown
in the appendices’and described in the results section. The hypothesis was accepted because the
studies showed that as obesity levels increased or remained the same, self-esteem levels
decreased between baseline and follow-up testing. Global self-worth and self-esteem was a
54
common factor for each study, so there were not any gaps or limitations to this component of the
study.
Studies by Dempster et al,(2008), Caterson et al, (2006), Gerrard et al, (2011), showed
that education levels of the parents contribute to a higher percentage of children with obesity.
Low scholastic competence of children and adolescents showed a higher prevalence of obesity as
well. In each study, children who had parents with low socioeconomic status, lower education
levels and who were most deprived showed an overall higher level of obesity which in turn
caused low self-esteem. It was found that low education and low self-esteem also are directly
correlated, as the appendix will show. There are limitations to this research because the
assumptions that lower education may lead to lower paying jobs, not being able to afford
healthier foods and gym memberships, and a lack of knowing what causes/prevents obesity may
all be contributing factors. These are all assumptions that are made because there are some
minor gaps in the research. Although there are some limitations to the research in regards to
education, the hypothesis is still accepted because education level was directly correlated to
childhood obesity.
The final conclusion from the research found that there were some major gaps and
limitations to the final question. Trying to determine if low self-esteem levels caused
psychological issues in the children proved to have limitations. Characteristics such as social
acceptance, competence, global self-worth, and physical appearance, were all components that
were a part of the questionnaire, but they did not directly answer how a child can suffer on a
psychological level. Each component above was shown to decrease as obesity levels increased,
but “psychological issues” were not defined so there were limitations as seen in the data of the
appendices’. In 1975, Hilde Bruche wrote, “There is no doubt that obesity is an undesirable state
55
of existence for a child. It is even more undesirable for an adolescent, for whom even mild
degrees of overweight may act as a damaging barrier in a society obsessed with slimness.”
There can be many conclusions drawn from the data and even from the above quote. The fact is
that there are still limitations in the research which may lead conclusions to be made that are not
factual. Therefore, there is not enough information to be able to accept the hypothesis at this
time.
Overall, the research on childhood obesity and self-esteem proved to be very useful
information. As the three questions were asked, it was found that each had a direct correlation
and built upon the others. For example, it can be said that lower education levels can be a
contributor of childhood/adolescent obesity which can cause low self-esteem among these
subjects. Psychological issues related to low self-esteem are prevalent, but it is not known to
what extent. As more research is done in this area, the gaps in the literature can help focus on
what further research needs to be done.
Summary
As the research has indicated, the prevalence of childhood obesity has been an
alarming trend across the United States. Obesity has affected seventeen percent of all children
and adolescents in the United States, which is triple the rate from one generation ago (CDC,
2013). Childhood obesity has negative consequences on physical health, but it also has a
negative impact on a child’s well-being. Research has proven that as a child’s obesity level
increases or remains the same, their self-esteem levels decrease. This was determined by studies
done from 2000 through 2011 (Caterson et al, (2006), Dempster et al, (2008), Gerrard et al,
(2011), and Hesketh et al, (2004) and Strauss (2000). Utilizing baseline and follow-up
questionnaires as well as taking BMI levels of the subjects proved to be effective in determining
56
self-esteem as well as education levels of the research subjects. Overall, the main research
studies that were used allowed us to determine that as obesity levels increased or remained the
same, self-esteem levels decreased. We also found that lower education levels of the parent and
low scholastic competence of the child affected obesity. Lower education levels are one
contributing factor to childhood obesity. Limitations were found when looking at how low selfesteem affects a child on a psychological level, but there is a correlation between the variables.
Lower education levels of the parent and lower scholastic competence levels of a child result in
higher obesity rates, causing lower levels of self-esteem. Although research was limited in
finding what low self-esteem does to a child on a psychological level, researchers have
concluded that, “There is no doubt that obesity is an undesirable state of existence for a child. It
is even more undesirable for an adolescent, for whom even mild degrees of overweight may act
as a damaging barrier in a society obsessed with slimness” (Hilde Bruche, 1975). It seems that
many may be setting up their own children for failure. In order to reverse this trend, the research
needs to focus on what can be done to educate and prevent instead of trying to fix the problem
after it has happened. This will not only lead to better health, but increased well-being for our
future generations.
57
Appendix A
Child Health Questionnaire Parent Form 50 (CHQ-PF50) Questions (HealthActCHQ,
2014).
In general, how would you rate your child's health?
Has your child been limited in any of the following activities due to health problems?
 Doing things that take a lot of energy, such as playing soccer or running
 Doing things that take some energy such as riding a bike or skating
 Ability (physically) to get around the neighborhood, playground, or school
 Walking one block or climbing one flight of stairs
 Bending, lifting/stooping; taking care of him/herself?
Has your child's school work or activities with friends been limited in any of the following
ways due to emotional difficulties or problems with his/her behavior?
 Limited in the kind of schoolwork or activities with friends he/she could do
 Limited in the amount of time he/she could spend on schoolwork or activities with
friends
 Limited in performing schoolwork or activities with friends?
Has your child's school work or activities with friends been limited in any of the following ways
due to problems with his/her physical health:
 Limited in the kind of schoolwork or activities with friends he/she could do
 Limited in the amount of time he/she could spend on schoolwork or activities with
friends?
How much bodily pain or discomfort has your child had?
How often has your child had bodily pain or discomfort?
How often did each of the following statements describe your child?
 Argued a lot
 Had difficulty concentrating or paying attention
 Lied/cheated
 Stole things
 Had tantrums?
Compared to other children your child's age, in general how would you rate his/her
behavior?
How much of the time do you think your child: felt like crying; felt lonely; acted nervous;
bothered or upset; cheerful?
How satisfied do you think your child has felt about: his/her school ability; athletic ability;
friendships; looks/appearance; family relationships; life overall?
58
My child seems to be less healthy than other children I know; My child has never been seriously
ill; When there is something going around my child usually catches it; I expect my child will
have a very healthy life; I worry more about my child's health than other people.
Compared to one year ago, how would you rate your child's health now?
How much emotional worry or concern did each of the following cause you - your child's
physical health; emotional well-being or behavior; attention or learning abilities?
Were you limited in the amount of time you had for your own needs because of your child's
- physical health; emotional well-being or behavior; attention or learning abilities?
How often has your child's health or behavior - limited the types of activities you could do
as a family
 Interrupted various everyday family activities
 Limited your ability as a family to "pick up and go"
 Caused tension or conflict
 Been a source of disagreements or arguments in your family
 Caused you to cancel or change plans (personal or work) at the last minute?
In general, how would you rate your family's ability to get along with one another?
Harter Self-Perception Profile for Children
A sample questionnaire of the Harter Self-Perception profile is found at the following site:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2914631/table/T5/
59
Appendix B
Table 1. Mean and SD scores for domains of self-perception by BMI, SES, and gender
categories
Self-perception
domains
Scholastic
Competence
Social Acceptance
Athletic Competence
Physical Appearance
Behavioral Conduct
Global Self-Worth
Explanatory Variables
BMI
Normal
Obese
n=153; 73% n=58; 27%
SES
Most deprived
n=94; 44%
Mean, SD
Mean, SD
2.81, .67
2.91, .66
2.95, .67
3.1, .64
2.83, .63
3.16, .60
2.78, .81
2.85, .77
2.87, .67
2.83, .85
2.97, .73
3.11, .58
Least deprived
n=117; 56%
Gender
Male
n=114; 54%
Female
n=97; 46%
Mean, SD
Mean, SD
Mean, SD
Mean, SD
2.74, .71
2.97, .70
2,93, .69
3, .76
2.79, .69
3.10, .61
2.85, .72
2.98, .67
2.93, .65
3.05, .67
2.93, .63
3.18, .58
2.86, .69
2.91, .68
3.13, .63
3.04, .70
2.76, .66
3.08, .54
2.76, .73
2.88, .71
2.70, .64
3.01, .73
3, .64
3.11, .66
Dempster, M., McCullough, N., Muldoon, O. (2008). Self-Perception in overweight and obese
children: a cross sectional study. Child: care, health, and development, 35, 3, 357-364.
60
Appendix C
Demographic Data at Enrollment and Follow-up, NLSY 1990-92, 1994-96
Baseline(%)
n=1520
Gender
Male
Female
Black
White
Hispanic
Family Income (% above median)
Obese (%)
50
50
36
24
40
37
17.2
Follow-up(%)
n=1090
49
51
36
22
42
39
17
Charts and graphs revised from data taken from:
Strauss, R. (2000). Childhood Obesity and Self-Esteem. Pediatrics 2000; 105;e15.
61
62
Appendix D
Sample description
Characteristic
N
(%)
Age
12
780
17.5
13
903
20.3
14
883
19.2
15
985
22.1
16
907
20.4
Male
2234
50.1
Female
2224
49.9
White
3035
68.1
Black
Hispanic
Other
378
668
377
8.5
15
8.5
Less than high school
1045
23.4
High school degree
1480
22.8
Some post-high school
education
2525
46.2
Associates degree
550
8.5
Bachelor's degree
1194
18.4
Some graduate education
/ degree
5749
95.7
NL/underweight
3253
73
Overweight
692
15.5
Obese
513
11.5
Excellent
1125
25.3
Good
1823
41
Average/below average
1500
33.7
Gender
Race
Parent Education
Overweight Status
School performance
Table revised from :
Gerrard, M., Kingsbury, J., McClure, A., Sargent, J., Tanski, S. (2011). Characteristics
Associated with Low Self-Esteem Among U.S. Adolescents. Academy of Pediatrics; 10(4):
238-44.e2. doi: 10.1016/j.acap.2010.03.007
63
Appendix E
Change in Global Self-Esteem (9 and 10 and 13-14 years of age) NLSY
Global Self-Esteem (9 & 10 year
olds)
Weight Status age 9 &
10
Nonobese
Obese
Difference
1+/-4.0
.9+/-4.4
.9+/-3.4
.6+/-3.6
1.3+/-4.5
0+/-3.2
-.4(-1.8-1.2)
.4(-1.8-2.5)
-.9(-2.3-.4)
1.5+/-4
.8+/-4.8
Hispanic
.1+/-4.2
-2.1+/-5.2
White
0+/-4.1
-1.9+/-5.0
-.6(-20-8)
-2.2(4.6.3)P=.07
-1.9(-3.5to.3)P<.05
Males
Black
Hispanic
White
Females
Black
Chart is derived from data taken from:
Strauss, R. (2000). Childhood Obesity and Self-Esteem. Pediatrics 2000; 105;e15.
64
Appendix F
Table 1
Relative Risk of Low Perceived Domain Competency and Global Self-Worth
underweight, overweight, and obese children compared with normal weight
Variable
Underweight
RR (95% CI)
Normal
Overweight
(baseline) RR (95% CI)
Obese
RR (95% CI)
Boys
Global Self-Worth
Social Acceptance
.89 (.32-2.46)
1.03 (.53-2.01)
1 1.69 (.93-3.97)
1 1.24 (.77-1.99)
2.52 (1.37-4.61)
1.29 (.74-2.27)
Girls
Global Self-Worth
Social Acceptance
.42 (.13-1.33)
1.36 (.83-2.20)
1 2.37 (1.42-3.95)
1 1.57 (1.01-2.45)
4.12 (2.56-6.63)
2.11 (1.33-3.35)
Table 2
Relative Risk of Low Perceived Domain Competency and Global Self-Worth
underweight, overweight, and obese children compared with normal weight
Variable
Underweight Normal
Overweight
RR (95% CI)
(baseline) RR (95% CI)
Obese
RR (95% CI)
BOYS
Scholastic Competence
.87(.43-1.76)
1.00(.601 1.65)
1.13(.632.02)
GIRLS
Scholastic Competence
.94(.55-1.60)
1 .76(.43-1.35)
1.29(.75-2.2)
Tables derived from data according to:
Caterson, I., Denyer, G., Franklin, J., Hill, A., Steinbeck, K. (2006). Obesity and Risk of Low
Self-Esteem: A Statewide Survey of Australian Children. Pediatrics Vol. 118, No. 6. Pp.
2481-2487.
65
Appendix G
Factors Associated with Low Self-Esteem: Bivariate Analysis
Characteristic
Weight Status
Normal/underweight
Overweight
Obese
School performance
Average/below average
Good
Excellent
Normal Selfesteem
N
(%)
2666
546
357
82
78.9
69.9
Low Self-esteem
N
(%)
587
146
156
P-value
p=0.000
18
21.1
30.4
p=0.000
825
1460
1276
73.3
80.1
85.1
300
363
224
26.7
19.9
14.9
Data taken and reproduced from:
Gerrard, M., Kingsbury, J., McClure, A., Sargent, J., Tanski, S. (2011).
Characteristics Associated with Low Self-Esteem Among U.S.
Adolescents. Academy of Pediatrics; 10(4): 238-44.e2. doi:
10.1016/j.acap.2010.03.007
66
Appendix H
Baseline and follow-up characteristics of retained cohort (n=1157)
Characteristic
Baseline
Mean, SD
Follow-up
Mean, SD
Age (years)
BMI (z score)
BMI category
Non-overweight
Overweight
Obese
Self-esteem Score
Self-esteem Category
Low (<15th percentile)
Not Low (>15th percn.)
7.6 (1.2)
.43(.85)
10.8(1.2)
.37(.93)
937(81)
174(15)
46(4)
87.5(15.3)
881(76)
227(20)
49(4)
83.3(14.7)
195(17)
962(83)
210(18)
947(82)
Chart revised from data:
Hesketh, K., Wake, M., Waters, E. (2004). Body mass index and parentreported self-esteem in elementary school children: evidence for a
causal relationship. International Journal of Obesity. 28: 1233-1237,
doi:10.1038/sj.ijo.0802624
67
Appendix I
Percentage of Children with Low Perceived Self-Competency and Global
Self-Worth in the Different Weight Categories
Variable
Underweight
% (n)
Normal
% (n)
Overweight
% (n)
Obese
% (n)
Total
% (n)
Social Acceptance
8.2 (9)
7.9(74)
9.8(20)
10.2(13) 8.4(111)
Behavioral Conduct
5.5(6)
8.9(79)
8.3(17)
6.3(8)
GIRLS
Scholastic Competence
9.6(14)
10.2(104)
7.7(12)
13.1(13) 10.1(143)
Behavioral Conduct
4.1(6)
4.6(47)
5.2(8)
3(3)
BOYS
8.3(110)
4.5(64)
Table derived from data according to:
Caterson, I., Denyer, G., Franklin, J., Hill, A., Steinbeck, K. (2006). Obesity and Risk of Low
Self-Esteem: A Statewide Survey of Australian Children. Pediatrics Vol. 118, No. 6. Pp.
2481-2487.
68
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