Adolescence is a developmental period marked by great physical change, and it is a time when many teens subject themselves to painful scrutiny. Uneven growth, puberty, and sexual maturation may make teens feel awkward and self-conscious about their bodies. Teenage girls are especially susceptible to developing negative body images—ignoring other qualities and focusing exclusively on appearance to measure their self-worth. This single-minded, and often distorted, destructive focus can result in lowered self-esteem and increased risk for mental health problems, including eating disorders.
Who Is at Risk?
Although there are biological, genetic, and familial factors that predispose to such eating disorders as anorexia nervosa (intense fear of becoming fat even when dangerously underweight) and bulimia (recurrent episodes of binge eating followed by purging to prevent weight gain) the emergence of these disorders is triggered by environmental factors. Chief among the environmental triggers is body image. Many researchers and health professionals believe that teenage girls who identify with the idealized body images projected throughout American culture are at increased risk for eating disorders.
Other risk factors are peer group pressures and such sociocultural forces as the fashion and entertainment industries and the media. The National Eating Disorders Association identifies media definitions of beauty, attractiveness, and health as among the myriad factors contributing to the rise of eating disorders. A landmark 1997 survey conducted by the Commonwealth Fund, In Their Own Words: Adolescent Girls Discuss Health and Health Care Issues, found that the media were their primary source of information about women's health issues. Another study found that in the course of twenty years three-quarters of articles about fitness or exercise plans in one teen adolescent magazine named "to become more attractive" as the reason to start exercising, and 51% cited the need to lose weight or burn calories.
Historically, the majority of adolescents with eating disorders have been first- or second-born white females from middle- to upper-class families. Girls who suffer from anorexia are often academically successful, with athletic prowess or training in dance. They tended to be perfectionists, well behaved, emotionally dependent, socially anxious, and intent on receiving approval from others. Adolescent girls with bulimia were generally more extroverted and socially involved. In the early twenty-first century the occurrence of eating disorders is increasing among younger children and throughout diverse ethnic and sociocultural groups. As many as 1% of adolescents have anorexia nervosa and between 2% and 3% suffer from bulimia.
According to the National Eating Disorders Association, surveys have found that preoccupation with thinness and dieting begins at an early age ("Statistics: Eating Disorders and Their Precursors," http://www.nationaleatingdisorders.org/). One study reported that 42% of first- to third-grade girls said they wanted to be thinner, and another found that 81% of ten-year-olds feared becoming fat. Between 30% and 40% of middle school girls are worried about their weight, and 40% to 60% of high school girls diet. A survey of female college students found that 91% had attempted to control their weight by dieting, and 22% said they were "often" or "always" dieting.
The 2003 Youth Risk Behavior Survey found that nationwide, 43.8% of high school students were trying to lose weight. The prevalence of trying to lose weight was higher among female (59.3%) than male (29.1%) students and higher among white females (62.6%) than African-American female students (46.7%). During the thirty days preceding the survey, 42.2% of students said they had eaten less food, fewer calories, or low-fat foods to lose weight. Table 4.14 shows the percentage of students who used healthy behaviors such as modifying their diets or exercising to control their weight.
Nationwide, 13.3% of students had gone without eating for twenty-four hours or more in an effort to lose weight during the thirty days, 9.2% had taken diet pills, powders, or liquids without a physician's advice, and 6% had vomited or taken laxatives to lose weight or keep from gaining weight. More female (8.4%) than male (3.7%) students had used this latter strategy, and the prevalence of vomiting or laxative use was higher among white (8.5%) and Hispanic female (9.7%) than African-American female (5.6%) students. Table 4.15 shows the
TABLE 4.14 Percentage of high school students who engaged in healthy behaviors associated with weight controla to lose or to keep from gaining weight, by sex, race/ethnicity, and grade, 2003
| TABLE 4.14 | |||||||
|---|---|---|---|---|---|---|---|
| Percentage of high school students who engaged in healthy behaviors associated with weight controla to lose or to keep from gaining weight, by sex, race/ethnicity, and grade, 2003 | |||||||
| Category | Ate less food, fewer calories, or foods low in fat to lose weight or to keep from gaining weight | Exercised to lose weight or to keep from gaining weight | |||||
| Female | Male | Total | Female | Male | Total | ||
| Percent | Percent | Percent | Percent | Percent | Percent | ||
| aDuring the 30 days preceding the survey. | |||||||
| bNon-Hispanic. | |||||||
| SOURCE: "Table 62. Percentage of High School Students Who Engaged in Healthy Behaviors Associated with Weight Control to Lose Weight or to Keep from Gaining Weight, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2003," in "Youth Risk Behavior Surveillance—United States, 2003," in Morbidity and Mortality Weekly Report Surveillance Summaries, vol.53, no. SS-2, Centers for Disease Control and Prevention, National Center for Health Statistics, May 21, 2004, http://www.cdc.gov/mmwr/PDF/SS/SS5302.pdf (accessed January 12, 2006) | |||||||
| Race/ethnicity | |||||||
| Whiteb | 61.1 | 29.1 | 44.6 | 69.6 | 48.1 | 58.5 | |
| Blackb | 39.0 | 21.8 | 30.5 | 49.2 | 46.1 | 47.5 | |
| Hispanic | 54.9 | 33.7 | 44.2 | 64.1 | 53.7 | 58.9 | |
| Grade | |||||||
| 9 | 53.0 | 28.8 | 40.4 | 65.7 | 50.2 | 57.6 | |
| 10 | 58.1 | 27.8 | 42.7 | 68.9 | 49.8 | 59.2 | |
| 11 | 56.4 | 29.4 | 42.8 | 64.5 | 49.4 | 56.8 | |
| 12 | 57.9 | 29.8 | 43.7 | 63.2 | 46.4 | 54.6 | |
| Total | 56.2 | 28.9 | 42.2 | 65.7 | 49.0 | 57.1 | |
Which Variables Are Associated with Dieting, Overweight, and Eating Disorders?
Dianne Neumark-Sztainer and Peter J. Hannan, researchers at the University of Minnesota, Minneapolis, analyzed a representative sample of 6,728 adolescents in grades five through twelve who completed the Commonwealth Fund surveys about the health of adolescent girls and boys. The objectives and results of the research were detailed in "Weight-Related Behaviors among Adolescent Girls and Boys: Results from a National Survey" (Archives of Pediatrics & Adolescent Medicine, vol. 154, no. 6, June 2000). The research aimed to assess the prevalence of dieting and disordered eating among adolescents; the sociodemographic, psychosocial, and behavioral variables that were associated with dieting and disordered eating; and whether adolescents report having discussed weight-related issues with their health-care providers. (The researchers defined disordered eating as weight-related behaviors such as anorexia and bulimia nervosa, self-induced vomiting, binge eating, inappropriate or extreme dieting, and obesity.)
Subjects were assessed by calculating BMI and eliciting weight-related attitudes and behaviors. For
TABLE 4.15 Percentage of high school students who engaged in unhealthy behaviors associated with weight controla, by sex, race/ethnicity, and grade, 2003
| TABLE 4.15 | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Percentage of high school students who engaged in unhealthy behaviors associated with weight controla, by sex, race/ethnicity, and grade, 2003 | |||||||||
| Category | Went without eating for >24 hours to lose welght or to keep from gaining welght | Took diet pills, powders, or liquids to lose welght or to keep from gaining welghtb | Vomited or took laxatives to lose weight or to keep from gaining welght | ||||||
| Female | Male | Total | Female | Male | Total | Female | Male | Total | |
| Percent | Percent | Percent | Percent | Percent | Percent | Percent | Percent | Percent | |
| aDuring the 30 days preceding the survey. | |||||||||
| bWithoukt a doctor's advice. | |||||||||
| cNon-Hispanic. | |||||||||
| SOURCE: "Table 64. Percentage of High School Students Who Engaged in Unhealthy Behaviors Associated with Weight Control, by Sex, Race/Ethnicity, and Grade—United States, Youth Risk Behavior Survey, 2003," in "Youth Risk Behavior Surveillance—United States, 2003," in Morbidity and Mortality Weekly Report Surveillance Summaries, vol. 53, no. SS-2, Centers for Disease Control and Prevention, National Center for Health Statistics, May 21, 2004, http://www.cdc.gov/mmwr/PDF/SS/SS5302.pdf (accessed January 12, 2006) | |||||||||
| Race/ethnicity | |||||||||
| Whitec | 18.4 | 7.1 | 12.5 | 13.0 | 6.8 | 9.8 | 8.5 | 2.7 | 5.5 |
| Blackc | 14.5 | 10.5 | 12.5 | 5.1 | 4.9 | 5.0 | 5.6 | 5.0 | 5.3 |
| Hispanic | 18.2 | 9.2 | 13.7 | 11.7 | 9.2 | 10.5 | 9.7 | 5.1 | 7.4 |
| Grade | |||||||||
| 9 | 18.8 | 10.7 | 14.6 | 9.2 | 7.0 | 8.0 | 7.9 | 4.6 | 6.2 |
| 10 | 18.5 | 7.0 | 12.7 | 10.9 | 5.8 | 8.3 | 9.3 | 3.5 | 6.4 |
| 11 | 19.6 | 8.2 | 13.8 | 12.6 | 7.7 | 10.1 | 8.8 | 2.6 | 5.7 |
| 12 | 15.7 | 6.9 | 11.2 | 13.0 | 8.5 | 10.8 | 7.3 | 3.8 | 5.5 |
| Total | 18.3 | 8.5 | 13.3 | 11.3 | 7.1 | 9.2 | 8.4 | 3.7 | 6.0 |
The study revealed that 24% of the population was overweight, with nearly half of the girls and 20%of the boys reporting a history of dieting. Twenty percent of the population reported disordered eating (13% of girls and 7% of boys), which was associated with a range of behavioral variables including overweight, low self-esteem, depression, suicidal ideation (thoughts, intent, or plans to take one's own life), and substance use. Nearly half of the adolescents recalled discussions about nutrition with a health-care provider, but just 24% of girls and 15% of boys said they had discussed eating disorders with a health-care provider.
Younger girls (grades five through eight) were significantly less likely to engage in dieting and disordered eating than older girls (grades nine through twelve), and dieting was reported by 31.1% of the fifth-grade girls and increased to 62.1% among twelfth-grade girls. The prevalence of disordered eating was highest among Hispanic girls and lowest among non-Hispanic African-American girls, and the prevalence of dieting was highest among white non-Hispanic girls and lowest among non-Hispanic African-American girls. The researchers observed that the prevalence rates of dieting behaviors were lowest among African-American girls, suggesting that black girls may experience lower levels of body dissatisfaction than white girls.
Alcohol and drug use were directly associated with dieting and disordered eating among girls and boys; however, the association between substance use and disordered eating was stronger than the association between substance use and dieting. Tobacco use was associated with dieting and disordered eating among girls, but not among boys.
The researchers were heartened to discover that "about half of the youth reported that a health-care provider had discussed nutrition and weight issues with them," and observed that while the content of such discussions was unclear, "at least the youth remembered that the issues had been discussed." They concluded that "the high rates of dieting and disordered eating behaviors, coupled with the high prevalence of obesity found in this and previous studies indicate a clear need for interventions aimed at the primary and secondary prevention of weight-related disorders. The large scope of the problem and the complexity of the issues at hand indicatethat there is a need for multiple interventions at the individual and familial level (e.g., within clinical practices), at the group level (e.g., within school settings), and at the community or larger societal level (e.g., changes in the physical and social environment)."
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